Unbalanced Medial-to-Lateral Knee Muscle Co-Contractions are Associated with Medial Tibiofemoral Underloading during Gait Three Months after Anterior Cruciate Ligament Reconstruction.

Altered medial/lateral knee muscle co-contraction (measure by co-contraction indices, CCI) occurs during gait early after anterior cruciate ligament reconstruction (ACLR). Changes in peak medial compartment forces (pMCF) are also observed early after ACLR and are linked to the development of knee osteoarthritis. We do not know if imbalanced co-contraction is associated with these alterations in knee load. The purpose of this study was to evaluate the association between pMCF and the CCIs of medial/lateral knee muscle pairs during walking three months after ACLR. Bilateral knee gait mechanics and electromyography (EMG) data were collected from 44 participants 3 months following surgery. CCIs of six muscle pairs and medial-to-lateral (M:L) CCIs ratios were calculated during the weight acceptance interval. Bilateral pMCFs were calculated using a subject-based neuromusculoskeletal model. Based on interlimb pMCF symmetry, participants were divided into three groups: symmetric loaders, underloaders, and overloaders. A 2 × 3 (limb × group) ANOVA was used to compare CCIs between limbs in all groups. A partial Spearman's test was performed to examine the association between CCIs ratios and pMCF. The CCIs of the vastus lateralis-lateral gastrocnemius muscle pair was higher in the involved limb of underloaders (vs. the uninvolved limb and vs. the involved limb of symmetric loaders). The ratio of M:L CCIs was significantly lower (more lateral CCIs) in the involved limb, which was associated with lower pMCF. These results suggest that individuals early after ACLR who walk with higher CCIs of lateral knee musculature (vs. medial), have medial tibiofemoral underloading.

Limb and sex-related differences in knee muscle co-contraction exist 3 months after anterior cruciate ligament reconstruction.

Interlimb and sex-based differences in gait mechanics and neuromuscular control are common after anterior cruciate ligament reconstruction (ACLR). Following ACLR, individuals typically exhibit elevated co-contraction of knee muscles, which may accelerate knee osteoarthritis (OA) onset. While directed (medial/lateral) co-contractions influence tibiofemoral loading in healthy people, it is unknown if directed co-contractions are present early after ACLR and if they differ across limbs and sexes. The purpose of this study was to compare directed co-contraction indices (CCIs) of knee muscles in both limbs between men and women after ACLR. Forty-five participants (27 men) completed overground walking at a self-selected speed 3 months after ACLR during which quadriceps, hamstrings, and gastrocnemii muscle activities were collected bilaterally using surface electromyography. CCIs of six muscle pairs were calculated during the weight acceptance interval. The CCIs of the vastus lateralis/biceps femoris muscle pair (lateral musculature) was greater in the involved limb (vs uninvolved; p = 0.02). Compared to men, women exhibited greater CCIs in the vastus medialis/lateral gastrocnemius and vastus lateralis/lateral gastrocnemius muscle pairs (p < 0.01 and p = 0.01, respectively). Limb- and sex-based differences in knee muscle co-contractions are detectable 3 months after ACLR and may be responsible for altered gait mechanics.

Patellofemoral contact forces after ACL reconstruction: A longitudinal study.

Osteoarthritis (OA) development after ACL reconstruction (ACLR) is common. Patellofemoral OA after ACLR is as prevalent as tibiofemoral OA; however, few have explored the mechanisms leading to disease development in this compartment. Biomechanical alterations may be one mechanism responsible for post-traumatic knee OA. Patellofemoral contact forces during dynamic tasks, such as running and single leg hops, have been assessed at return to sport and later time points. The results of these studies, however, contradict each other, are only cross-sectional in nature, and are limited to specific points in time within the movement pattern. The purpose of this study was to assess patellofemoral contact forces 3, 6, and 24 months after ACLR during level walking over the entirety of the movement pattern. Patellofemoral contact forces were calculated after determination of muscle forces from a validated, subject-specific, EMG-driven neuromusculoskeletal model. Statistical parametric mapping was used to compare patellofemoral contact forces between limbs and across time points. Patellofemoral underloading of the involved limb (vs. uninvolved) was present at 3 months (p < 0.001 from 7 to 30% of stance) and 6 months (p = 0.001 from 11 to 23% of stance and p = 0.025 from 27 to 32%) after ACLR but was resolved by 24 months. Both limbs' load increased from 3 to 6 months. The involved limb displayed relatively consistent loads from 6 months onward, while the uninvolved limb's decreased back down towards their 3-month values. Overall, these results suggest that early patellofemoral underloading exists after ACLR and may be leading to patellofemoral OA development.

Knee joint biomechanics during gait improve from 3 to 6 months after anterior cruciate ligament reconstruction.

Gait alterations after anterior cruciate ligament reconstruction (ACLR) are commonly reported and have been linked to posttraumatic osteoarthritis development. While knee gait alterations have been studied at several time points after ACLR, little is known about how these biomechanical variables change earlier than 6 months after surgery, nor is much known about how they differ over the entire stance phase of gait. The purpose of this study was to examine knee gait biomechanical variables over their entire movement pattern through stance at both 3 and 6 months after ACLR and to study the progression of interlimb asymmetry between the two postoperative time points. Thirty-five individuals underwent motion analysis during overground walking 3 (3.2 ± 0.5) and 6 (6.4 ± 0.7) months after ACLR. Knee biomechanical variables were compared between limbs and across time points through 100% of stance using statistical parametric mapping; this included a 2 × 2 (Limb × Time) repeated measures analysis of variance and two-tailed t-tests. Smaller knee joint angles, moments, extensor forces, and medial compartment forces were present in the involved versus uninvolved limb. Interlimb asymmetries were present at both time points but were less prevalent at 6 months. The uninvolved limb's biomechanical variables stayed relatively consistent over time, while the involved limb's trended toward that of the uninvolved limb. Statement of Clinical Significance: Interventions to correct asymmetrical gait patterns after ACLR may need to occur early after surgery and may need to focus on multiple parts of stance phase.

Knee cartilage T2 relaxation times 3 months after ACL reconstruction are associated with knee gait variables linked to knee osteoarthritis.

Osteoarthritis development after ACL reconstruction (ACLR) is not well understood. Investigators have examined associations between knee biomechanical alterations and quantitative MRI (qMRI) variables, reflective of cartilage health, 12-60 months following ACLR; however, none have done so early after surgery. As part of an exploratory study, 45 individuals (age, 23 ± 7 years) underwent motion analysis during walking and qMRI 3 months after ACLR. For each limb, peak knee adduction moment (pKAM) and peak knee flexion moment (pKFM) were determined using inverse dynamics and peak medial compartment force was calculated using a neuromusculoskeletal model. T2 relaxation times in the medial compartment and linear regressions were used to determine the associations between gait variables and deep and superficial cartilage T2 relaxation times in six regions. pKAM was positively associated with deep layer T2 relaxation times within the femoral central and posterior regions when examined in the involved limb and from an interlimb difference perspective (involved limb - uninvolved limb). After adjusting for age, the association between interlimb difference of pKAM and interlimb difference of deep layer T2 relaxation times in the tibial central region became significant (p = .043). Interlimb difference of pKFM was negatively associated with interlimb difference of deep layer T2 relaxation times within the femoral central and posterior regions. These associations suggest that degenerative pathways leading to osteoarthritis may be detectable as early as 3 months after reconstruction. Preventative therapeutic techniques may need to be employed early in the rehabilitation process to prevent cartilage degradation.

An Efficient One-Step Moment Balancing Algorithm for Computing Medial and Lateral Knee Compartment Contact Forces.

The knee adduction moment is associated with the progression of knee osteoarthritis (OA). The adduction moment reflects the net effect of muscles, passive tissues and bone-on-bone contact forces. Medial compartment OA is more common than lateral and therefore our ability to correctly partition bone-on-bones forces across the medial and lateral compartments is key to understanding mechanical factors associated with the onset and progression of knee OA. In this technical brief we present an efficient one-step moment balancing algorithm linking the sagittal and frontal planes in the determination of musculotendon forces. Novel to the one-step approach is the introduction of a penalty function limiting total compressive force from acting in the lateral compartment when the internal moment is net abduction (i.e., external knee adduction). Medial and lateral knee contact forces were computed using the one-step moment balancing algorithm for 10 subjects walking at a self-selected pace and compared to values determined using a well-established two-step frontal moment balancing approach. Overall, average peak differences in magnitude and timing were small and the ensemble-averaged contact force profiles were similar between methods. The only statistical difference was slightly larger (0.2 BWs) peak medial contact force for the one-step method during the first half of stance, however these differences are small relative to peak values and would not likely alter interpretation of the data. The 1-step moment balancing method is a more efficient methodology for computing medial and lateral knee contact forces that can be used in place of two-step frontal plane moment balancing.

The cross-sectional relationships between age, standing static balance, and standing dynamic balance reactions in typically developing children.

BACKGROUND: Static balance performance is a common metric for evaluating the development of postural control in children. Less is known about the potentially independent development of dynamic balance performance. RESEARCH QUESTION: How does age relate to static (i.e. postural sway) and dynamic (i.e. stepping thresholds) standing balance performance, and what is the relationship between postural sway and stepping thresholds? METHODS: Twenty-six typically developing children (12 males, 14 females; 5-12 years of age) were recruited for this cross-sectional study. Static balance performance was quantified as the total path length during a postural sway assessment using a force platform with conditions of eyes open and eyes closed. Dynamic balance performance was quantified using a single-stepping threshold assessment, whereby participants attempted to prevent a step in response to treadmill-induced perturbations in the anterior and posterior directions. Relationships between age and body-size scaled measures of static and dynamic balance performance were assessed using Spearman rank correlations. RESULTS: There was a weak correlation between age and postural sway (|rs| < 0.10, p >  0.68), but a moderate-to-strong correlation between age and single-stepping thresholds (rs > 0.68, p < 0.001). A weak correlation was found between postural sway and single-stepping thresholds (|rs| < 0.20, p >  0.39). SIGNIFICANCE: Dynamic, but not static standing balance performance, may improve with typical development between the ages of 5 and 12 years. Static and dynamic balance should be considered as unique constructs when assessed in children.

Gait Mechanics in Women of the ACL-SPORTS Randomized Control Trial: Interlimb Symmetry Improves Over Time Regardless of Treatment Group.

Women after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) are more likely than men to exhibit asymmetric movement patterns, which are associated with post-traumatic osteoarthritis. We developed the ACL specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of strength, agility, plyometric, and secondary prevention (SAPP) training with and without perturbation training (SAPP + PERT) on gait mechanics in women after ACLR. We hypothesized that movement symmetry would improve over time across both groups but more so among the SAPP + PERT group. Thirty-nine female athletes 3-9 months after primary ACLR were randomized to SAPP or SAPP + PERT training. Biomechanical testing during overground walking occurred before (Pre-training) and after (Post-training) training and one and 2 years post-operatively. Hip and knee kinematic and kinetic variables were compared using repeated measures analysis of variance with Bonferroni corrections for post hoc comparisons (α = 0.05). There was a time by limb interaction effect (p = 0.028) for peak knee flexion angle (PKFA), the primary outcome which powered the study, characterized by smaller PKFA in the involved compared to uninvolved limbs across treatment groups at Pre-training, Post-training, and 1 year, but not 2 years. Similar findings occurred across sagittal plane knee excursions and kinetics and hip extension excursion at midstance. There were no meaningful interactions involving group. Neither SAPP nor SAPP + PERT training improved walking mechanics, which persisted 1 but not 2 years after ACLR. Statement of clinical significance: Asymmetrical movement patterns persisted long after participants achieved symmetrical strength and functional performance, suggesting more time is needed to recover fully after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1743-1753, 2019.

Changes in gait mechanics and muscle activity with wedge height in an orthopaedic boot.

BACKGROUND: Orthopaedic boots with wedging are commonly used in the treatment of individuals with Achilles tendon rupture to immobilize the foot in plantar flexion and approximate tendon ends. RESEARCH QUESTION: To describe changes in muscle activity of the triceps surae and gait mechanics with the use of wedges in an orthopaedic boot immediately and after an accommodation period. METHODS: Muscle activity of the triceps surae and gait parameters (vertical ground reaction force, knee extension power, gait speed) were collected using surface electromyography and motion capture in 12 healthy individuals. Participants walked in an instrumented orthopaedic boot with 0, 3, and 5 wedges tested in random order. Participants were provided a one hour accommodation period where time spent walking was collected. This was followed by a repeat assessment of triceps surae activity and gait. RESULTS: Peak and integrated EMG in the medial gastrocnemius (p = 0.001, p < 0.001) and soleus (p = 0.010, p < 0.001) significantly decreased with increasing number of wedges. Peak and integrated EMG had a slight but non-significant decrease with increasing number of wedges in the lateral gastrocnemius (p = 0.151, p = 0.077). Vertical ground reaction force decreased (p = 0.019) and peak knee extension power increased (p = 0.003) with increasing number of wedges. There were no statistically significant differences in gait speed with wedges (p = 0.450). There were no significant changes in EMG or gait parameters from pre- to post-accommodation period. SIGNIFICANCE: A combination of factors yield decreased triceps surae activity in individuals wearing an orthopaedic boot with wedges - decreasing loading on the immobilized limb and shifting power generation proximally.

High muscle co-contraction does not result in high joint forces during gait in anterior cruciate ligament deficient knees.

The mechanism of knee osteoarthritis development after anterior cruciate ligament injuries is poorly understood. The objective of this study was to evaluate knee gait variables, muscle co-contraction indices and knee joint loading in young subjects with anterior cruciate ligament deficiency (ACLD, n = 36), versus control subjects (n = 12). A validated, electromyography-informed model was used to estimate joint loading. For the involved limb of ACLD subjects versus control, muscle co-contraction indices were higher for the medial (p = 0.018, effect size = 0.93) and lateral (p = 0.028, effect size = 0.83) agonist-antagonist muscle pairs. Despite higher muscle co-contraction, medial compartment contact force was lower for the involved limb, compared to both the uninvolved limb (mean difference = 0.39 body weight, p = 0.009, effect size = 0.70) as well as the control limb (mean difference = 0.57 body weight, p = 0.007, effect size = 1.14). Similar observations were made for total contact force. For involved versus uninvolved limb, the ACLD group demonstrated lower vertical ground reaction force (mean difference = 0.08 body weight, p = 0.010, effect size = 0.70) and knee flexion moment (mean difference = 1.32% body weight * height, p = 0.003, effect size = 0.76), during weight acceptance. These results indicate that high muscle co-contraction does not always result in high knee joint loading, which is thought to be associated with knee osteoarthritis. Long-term follow-up is required to evaluate how gait alterations progress in non-osteoarthritic versus osteoarthritic subjects. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Gait Mechanics After ACL Reconstruction Differ According to Medial Meniscal Treatment.

BACKGROUND: Knee osteoarthritis risk is high after anterior cruciate ligament reconstruction (ACLR) and arthroscopic meniscal surgery, and higher among individuals who undergo both. Although osteoarthritis development is multifactorial, altered walking mechanics may influence osteoarthritis progression. The purpose of this study was to compare gait mechanics after ACLR among participants who had undergone no medial meniscal surgery, partial medial meniscectomy, or medial meniscal repair. METHODS: This was a secondary analysis of data collected prospectively as part of a clinical trial. Sixty-one athletes (mean age of 21.4 ± 8.2 years) who had undergone primary ACLR participated in the study when they achieved impairment resolution (5.3 ± 1.7 months postoperatively), including minimal to no effusion, full knee range of motion, and ≥80% quadriceps-strength symmetry. Participants were classified by concomitant medial meniscal treatment: no involvement or nonsurgical management of a small, stable tear; partial meniscectomy; or meniscal repair. Participants underwent comprehensive walking analyses. Joint contact forces were estimated using a previously validated, electromyography-driven musculoskeletal model. Variables were analyzed using a mixed-model analysis of variance with group and limb comparisons (α = 0.05); group comparisons of interlimb differences in measurements (surgical minus contralateral limb) were performed to determine significant interactions. RESULTS: The participants in the partial meniscectomy group walked with a higher peak knee adduction moment (pKAM) in the surgical versus the contralateral limb as compared with those in the meniscal repair group and those with no medial meniscal surgery (group difference for partial versus repair: 0.10 N-m/kg-m, p = 0.020; and for partial versus none: 0.06 N-m/kg-m, p = 0.037). Participants in the repair group walked with a smaller percentage of medial to total tibiofemoral loading in the surgical limb compared with both of the other groups (group difference for repair versus partial: -12%, p = 0.001; and for repair versus none: -7%, p = 0.011). The participants in the repair group loaded the medial compartment of the surgical versus the contralateral limb 0.5 times body weight less than did the participants in the partial meniscectomy group. CONCLUSIONS: Participants in the partial meniscectomy group walked with higher pKAM and shifted loading toward the medial compartment of the surgical limb, while participants in the repair group did the opposite, walking with lower pKAM and unloading the surgical limb relative to the contralateral limb. These findings may partially explain the conflicting evidence regarding pKAM after ACLR and the elevated risk for osteoarthritis (whether from overloading or underloading) after ACLR with concomitant medial meniscectomy or repair. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gait mechanics and tibiofemoral loading in men of the ACL-SPORTS randomized control trial.

The risk for post-traumatic osteoarthritis is elevated after anterior cruciate ligament reconstruction (ACLR), and may be especially high among individuals with aberrant walking mechanics, such as medial tibiofemoral joint underloading 6 months postoperatively. Rehabilitation training programs have been proposed as one strategy to address aberrant gait mechanics. We developed the anterior cruciate ligament specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of 10 post-operative training sessions consisting of strength, agility, plyometric, and secondary prevention exercises (SAPP) or SAPP plus perturbation (SAPP + PERT) training on gait mechanics after ACLR. A total of 40 male athletes (age 23 ± 7 years) after primary ACLR were randomized to SAPP or SAPP + PERT training and tested at three distinct, post-operative time points: 1) after impairment resolution (Pre-training); 2) following 10 training sessions (Post-training); and 3) 2 years after ACLR. Knee kinematic and kinetic variables as well as muscle and joint contact forces were calculated via inverse dynamics and a validated electromyography-informed musculoskeletal model. There were no significant improvements from Pre-training to Post-training in either intervention group. Smaller peak knee flexion angles, extension moments, extensor muscle forces, medial compartment contact forces, and tibiofemoral contact forces were present across group and time, however the magnitude of interlimb differences were generally smaller and likely not meaningful 2 years postoperatively. Neither SAPP nor SAPP + PERT training appears effective at altering gait mechanics in men in the short-term; however, meaningful gait asymmetries mostly resolved between post-training and 2 years after ACLR regardless of intervention group. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2364-2372, 2018.

The Advantages of Normalizing Electromyography to Ballistic Rather than Isometric or Isokinetic Tasks.

Isometric tasks have been a standard for electromyography (EMG) normalization stemming from anatomic and physiologic stability observed during contraction. Ballistic dynamic tasks have the benefit of eliciting maximum EMG signals for normalization, despite having the potential for greater signal variability. It is the purpose of this study to compare maximum voluntary isometric contraction (MVIC) to nonisometric tasks with increasing degrees of extrinsic variability, ie, joint range of motion, velocity, rate of contraction, etc., to determine if the ballistic tasks, which elicit larger peak EMG signals, are more reliable than the constrained MVIC. Fifteen subjects performed MVIC, isokinetic, maximum countermovement jump, and sprint tasks while EMG was collected from 9 muscles in the quadriceps, hamstrings, and lower leg. The results revealed the unconstrained ballistic tasks were more reliable compared to the constrained MVIC and isokinetic tasks for all triceps surae muscles. The EMG from sprinting was more reliable than the constrained cases for both the hamstrings and vasti. The most reliable EMG signals occurred when the body was permitted its natural, unconstrained motion. These results suggest that EMG is best normalized using ballistic tasks to provide the greatest within-subject reliability, which beneficially yield maximum EMG values.

Predictors of knee joint loading after anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) injury results in altered knee joint mechanics which frequently continue even after ACL reconstruction. The persistence of altered mechanical loading of the knee is of concern due to its likely role in the development of post-traumatic osteoarthritis (OA). Joint contact forces are associated with post-traumatic OA development, but evaluation of factors influencing the magnitude of contact forces after ACL injury is needed to advance current strategies aimed at preventing post-traumatic OA. Therefore, the purpose of this study was to identify predictive factors of knee joint contact forces after ACL reconstruction. Thirty athletes completed standard gait analysis with surface electromyography 6 months after ACL reconstruction. An electromyographic-driven musculoskeletal model was used to estimate joint contact forces. External knee adduction moment was a significant predictor of medial compartment contact forces in both limbs, while vertical ground reaction force and co-contraction only contributed significantly in the uninvolved limb. The large influence of the knee adduction moment on joint contact forces provides mechanistic clues to understanding the mechanical pathway of post-traumatic OA after ACL injury. Statement of Clinical Significance: This study provides critical information in improving the understanding of mechanisms influencing the development of post-traumatic OA after ACL injury. Further work is needed to identify additional driving factors of joint loading in the ACL-injured limb and develop treatment strategies to avert the deleterious consequences of post-traumatic OA. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:651-656, 2017.

Gait mechanics and second ACL rupture: Implications for delaying return-to-sport.

Second anterior cruciate ligament rupture is a common and devastating injury among young women who return to sport after ACL reconstruction, but it is inadequately understood. The purpose of this study was to compare gait biomechanics and return-to-sport time frames in a matched cohort of young female athletes who, after primary ACLR, returned to sport without re-injury or sustained a second ACL injury. Approximately 6 months after primary reconstruction, 14 young women (age 16 ± 2 years) involved in jumping, cutting, and pivoting sports underwent motion analysis testing after physical therapy and impairment resolution. Following objective return-to-sport clearance, seven athletes sustained a second ACL rupture within 20 months of surgery (13.4 ± 4.9 months). We matched them by age, sex, and sport-level to seven athletes who returned to sports without re-injury. Data were analyzed using a previously validated, EMG-informed, patient-specific musculoskeletal model. Compared to athletes without re-injury, athletes who sustained a second ACL injury received surgery sooner (p = 0.023), had post-operative impairments resolved earlier (p = 0.022), reached criterion-based return-to-sport benchmarks earlier (p = 0.024), had higher body mass index (p = 0.039), and walked with lower peak knee flexor muscle forces bilaterally (p = 0.021). Athletes who sustained a second injury also tended to walk with larger (p = 0.089) and more symmetrical peak knee flexion angles and less co-contraction, all indicative of a more normal gait pattern. Statement of Clinical Significance: Delayed return-to-sport clearance even in the absence of gait or clinical impairments following primary ACL reconstruction may be necessary to mitigate second ACL injury risk in young women. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1894-1901, 2017.

Gait mechanics in those with/without medial compartment knee osteoarthritis 5 years after anterior cruciate ligament reconstruction.

The objective of the study was to evaluate differences in gait mechanics 5 years after unilateral anterior cruciate ligament reconstruction surgery, for non-osteoarthritic (n = 24) versus osteoarthritic (n = 9) subjects. For the involved knee, the osteoarthritic group demonstrated significantly lower peak knee flexion angles (non-osteoarthritic = 24.3 ± 4.6°, osteoarthritic = 19.1 ± 2.9°, p = 0.01) and peak knee flexion moments (non-osteoarthritic = 5.3 ± 1.2% Body Weight × Height, osteoarthritic = 4.4 ± 1.2% Body Weight × Height, p = 0.05). Differences in peak knee adduction moment approached significance, with a higher magnitude for the osteoarthritic group (non-osteoarthritic = 2.4 ± 0.8% Body Weight × Height, osteoarthritic = 2.9 ± 0.5% Body Weight × Height, p = 0.09). Peak medial compartment joint load was evaluated using electromyography-informed neuromusculoskeletal modeling. Peak medial compartment joint load in the involved knee for the two groups was not different (non-osteoarthritic = 2.4 ± 0.4 Body Weight, osteoarthritic = 2.3 ± 0.6 Body Weight). The results suggest that subjects with dissimilar peak knee moments can have similar peak medial compartment joint load magnitudes. There was no evidence of inter-limb asymmetry for either group. Given the presence of inter-group differences (non-osteoarthritic vs. osteoarthritic) for the involved knee, but an absence of inter-limb asymmetry in either group, it may be necessary to evaluate how symmetry is achieved, over time, and to differentiate between good versus bad inter-limb symmetry, when evaluating knee gait parameters. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:625-633, 2017.

Biomechanical analysis of gait termination in 11-17year old youth at preferred and fast walking speeds.

In populations where walking and/or stopping can be difficult, such as in children with cerebral palsy, the ability to quickly stop walking may be beyond the child's capabilities. Gait termination may be improved with physical therapy. However, without a greater understanding of the mechanical requirements of this skill, treatment planning is difficult. The purpose of this study was to understand how healthy children successfully terminate gait in one step when walking quickly, which can be challenging even for healthy children. Lower extremity kinematic and kinetic data were collected from 15 youth as they performed walking, planned, and unplanned stopping tasks. Each stopping task was performed as the subject walked at his/her preferred speed and a fast speed. The most significant changes in mechanics between speed conditions (preferred and fast) of the same stopping task were greater knee flexion angles (unplanned: +16.49±0.54°, p=0.00; planned: +15.75±1.1°, p=0.00) and knee extension moments (unplanned: +0.67±0.02N/kgm, p=0.00; planned: +0.57±0.23N/kgm, p=0.00) at faster speeds. The extra range of motion in the joints and extra muscle strength required to maintain the stopping position suggests that stretching and strengthening the muscles surrounding the joints of the lower extremity, particularly the knee, may be a useful intervention.

Site-Specific Transmission of a Floor-Based, High-Frequency, Low-Magnitude Vibration Stimulus in Children With Spastic Cerebral Palsy.

OBJECTIVE: To determine the degree to which a high-frequency, low-magnitude vibration signal emitted by a floor-based platform transmits to the distal tibia and distal femur of children with spastic cerebral palsy (CP) during standing. DESIGN: Cross-sectional study. SETTING: University research laboratory. PARTICIPANTS: Children with spastic CP who could stand independently (n=18) and typically developing children (n=10) (age range, 4-12y) participated in the study (N=28). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The vibration signal at the high-frequency, low-magnitude vibration platform (approximately 33Hz and 0.3g), distal tibia, and distal femur was measured using accelerometers. The degree of plantar flexor spasticity was assessed using the Modified Ashworth Scale. RESULTS: The high-frequency, low-magnitude vibration signal was greater (P<.001) at the distal tibia than at the platform in children with CP (.36±.06g vs .29±.05g) and controls (.40±.09g vs .24±.07g). Although the vibration signal was also higher at the distal femur (.35±.09g, P<.001) than at the platform in controls, it was lower in children with CP (.20±.07g, P<.001). The degree of spasticity was negatively related to the vibration signal transmitted to the distal tibia (Spearman ρ=-.547) and distal femur (Spearman ρ=-.566) in children with CP (both P<.05). CONCLUSIONS: A high-frequency, low-magnitude vibration signal from a floor-based platform was amplified at the distal tibia, attenuated at the distal femur, and inversely related to the degree of muscle spasticity in children with spastic CP. Whether this transmission pattern affects the adaptation of the bones of children with CP to high-frequency, low-magnitude vibration requires further investigation.

Decreased Knee Joint Loading Associated With Early Knee Osteoarthritis After Anterior Cruciate Ligament Injury.

BACKGROUND: Anterior cruciate ligament (ACL) injury predisposes individuals to early-onset knee joint osteoarthritis (OA). Abnormal joint loading is apparent after ACL injury and reconstruction. The relationship between altered joint biomechanics and the development of knee OA is unknown. HYPOTHESIS: Altered knee joint kinetics and medial compartment contact forces initially after injury and reconstruction are associated with radiographic knee OA 5 years after reconstruction. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Individuals with acute, unilateral ACL injury completed gait analysis before (baseline) and after (posttraining) preoperative rehabilitation and at 6 months, 1 year, and 2 years after reconstruction. Surface electromyographic and knee biomechanical data served as inputs to an electromyographically driven musculoskeletal model to estimate knee joint contact forces. Patients completed radiographic testing 5 years after reconstruction. Differences in knee joint kinetics and contact forces were compared between patients with and those without radiographic knee OA. RESULTS: Patients with OA walked with greater frontal plane interlimb differences than those without OA (nonOA) at baseline (peak knee adduction moment difference: 0.00 ± 0.08 N·m/kg·m [nonOA] vs -0.15 ± 0.09 N·m/kg·m [OA], P = .014; peak knee adduction moment impulse difference: -0.001 ± 0.032 N·m·s/kg·m [nonOA] vs -0.048 ± 0.031 N·m·s/kg·m [OA], P = .042). The involved limb knee adduction moment impulse of the group with osteoarthritis was also lower than that of the group without osteoarthritis at baseline (0.087 ± 0.023 N·m·s/kg·m [nonOA] vs 0.049 ± 0.018 N·m·s/kg·m [OA], P = .023). Significant group differences were absent at posttraining but reemerged 6 months after reconstruction (peak knee adduction moment difference: 0.02 ± 0.04 N·m/kg·m [nonOA] vs -0.06 ± 0.11 N·m/kg·m [OA], P = .043). In addition, the OA group walked with lower peak medial compartment contact forces of the involved limb than did the group without OA at 6 months (2.89 ± 0.52 body weight [nonOA] vs 2.10 ± 0.69 body weight [OA], P = .036). CONCLUSION: Patients who had radiographic knee OA 5 years after ACL reconstruction walked with lower knee adduction moments and medial compartment joint contact forces than did those patients without OA early after injury and reconstruction.

Compensatory muscle activation caused by tendon lengthening post-Achilles tendon rupture.

PURPOSE: The purpose of this study was to establish a relationship between the lengthening of the Achilles tendon post-rupture and surgical repair to muscle activation patterns during walking in order to serve as a reference for post-surgical assessment. METHOD: The Achilles tendon lengths were collected from 4 patients with an Achilles tendon rupture 6 and 12 months post-surgery along with 5 healthy controls via ultrasound. EMG was collected from the triceps surae muscles and tibialis anterior during overground walking. RESULTS: Achilles lengths at 6 and 12 months post-surgery were significantly longer (p < 0.05) on the involved side compared to the uninvolved side, but there were no side-to-side differences in the healthy controls. The integrated EMG (iEMG) of the involved side was significantly higher than the uninvolved side in the lateral gastrocnemius at 6 months and for the medial gastrocnemius at 12 months in the patients with Achilles tendon rupture; no side-to-side difference was found in the healthy controls. The triceps surae muscles' activations were fair to moderately correlated to the Achilles lengths (0.38 < r < 0.52). CONCLUSIONS: The increased Achilles tendon length and iEMG from the triceps surae muscles indicate that loss of function is primarily caused by anatomical changes in the tendon and the appearance of muscle weakness is due to a lack of force transmission capability. This study indicates that when aiming for full return of function and strength, an important treatment goal appears to be to minimize tendon elongation.