Kinematic differences between neutral and flat feet with and without symptoms as measured by the Oxford foot model.

BACKGROUND: Flatfoot is a common presentation in children. It is usually asymptomatic, though a small number of children experience pain. Foot function during flatfoot walking is rarely considered, yet as an activity that places significant demands on the feet, this could explain the differences in terms of symptoms. RESEARCH QUESTION: This paper investigates walking patterns in neutral and flat feet, with and without symptoms, to determine which kinematic parameters are associated with symptomatic flat feet. METHODS: This is a retrospective study in which one hundred and six children between five and 18 years old were assessed by a physiotherapist for foot posture. Each foot was classified into one of four groups, giving 98 asymptomatic neutral, 47 asymptomatic mild flat, 29 asymptomatic flat, and 38 symptomatic flat feet with complete data for analysis. Using Plug-In-Gait and Oxford-Foot-Model markers, walking kinematics were measured, along with ground reaction forces. Median values of 14 lower limb joint angles were calculated at foot strike, midstance, and foot off. Each foot was treated as an independent sample. ANOVA and ANCOVA (with the speed-related variable relative stride length as the covariate) and post-hoc tests were used to assess whether angles differed between groups. RESULTS: The symptomatic flat feet showed significant differences from asymptomatic groups (most commonly the neutral feet) in terms of hip flexion, knee flexion and varus, hindfoot inversion-eversion, and forefoot abduction-adduction. Increased forefoot abduction occurred throughout stance phase in symptomatic flatfooted participants compared to all asymptomatic groups. SIGNIFICANCE: The results suggest that foot motion in the transverse plane is closely associated with the presence of symptoms in flat feet and that this is accompanied by changes in the kinematics of the ankle, knee, and hip.

An investigation into the aetiology of flexible flat feet: the role of subtalar joint morphology.

AIMS: There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture. PATIENTS AND METHODS: A total of 84 children aged between eight and 15 years old were prospectively recruited. The BMI for each child was calculated, flexibility was assessed using the lower limb assessment scale (LLAS) and foot posture was quantified using the arch height index (AHI). Each child underwent a sagittal T1-weighted MRI scan of at least one foot. RESULTS: An absent anterior subtalar articulation (p < 0.001) and increased LLAS (p = 0.001) predicted a low AHI. BMI was not a significant predictive factor (p = 0.566). CONCLUSION: This is the first study to demonstrate the importance of the morphology of the subtalar joint on the underlying foot posture in vivo. TAKE HOME MESSAGE: Flexibility of the lower limb and absence of the anterior facet of the subtalar joint are associated with flexible FF and may influence management of this common condition.

Are flexible flat feet associated with proximal joint problems in children?

The role of flexible flat feet (FF) in the development of musculoskeletal symptoms at joints proximal to the ankle is unclear. We undertook an observational study to investigate the relationship between foot posture and the proximal joints in children. It was hypothesised that reduced arch height would be associated with proximal joint symptoms and altered gait kinematics and kinetics particularly in the transverse plane at the hip and knee. Ninety-five children between the ages of 8-15 were recruited into this ethically approved study. Foot posture was classified using the arch height index (AHI). The frequency of knee and hip/back pain was documented, and each child underwent three dimensional gait analysis. Reduced arch height was associated with increased odds of knee symptoms (p<0.01) and hip/back symptoms (p=0.01). A flat foot posture was also significantly associated with a reduction in the second peak of the vertical ground reaction force (p=0.03), which concomitantly affected late stance hip and knee moments. A reduced AHI was also associated with increased pelvic retraction and increased knee valgus in midstance. No kinematic and kinetic parameter associated with a flat foot posture related to increased proximal joint symptoms in the FF group. Children with a flatter foot posture are more likely to have pain or discomfort at the knee, hip and back; however, the mechanisms by which this occurs remain unclear. Treating FF without explicit understanding of how it relates to symptoms is difficult, and further work in this area is required.

The relationship between quality of life and foot function in children with flexible flatfeet.

Flat feet in children are common, and at times symptomatic, but the relationship between function and symptoms or impairment is still unclear. We undertook a prospective, observational study comparing children with paediatric flexible flat foot (PFF) and children with neutral feet (NF) using three dimensional gait analysis (3DGA). It was hypothesised that children with PFF would demonstrate differences in both spatio-temporal parameters of gait and foot and ankle kinematics compared to the NF group and that these differences would correlate with impaired quality of life (QoL). The kinematic differences were expected to be most marked in hindfoot coronal plane motion and forefoot sagittal and transverse plane motion. Eighty-three children between the ages of 8 and 15 were recruited in this study: Forty-two were classified as having PFF and forty-one as NF. Each child underwent 3DGA and completed the Oxford Ankle Foot Questionnaire for Children (OxAFQ_C). Reduced OxAFQ_C physical domain scores in the PFF children were associated with slower walking speed (p=0.014) and reduced normalised stride length (p=0.008). PFF children also demonstrated significantly increased hindfoot eversion and forefoot supination during gait. Significant differences between groups were not observed for other foot and ankle joint motions. Increased maximum hindfoot eversion and increased forefoot supination correlated strongly with lower QoL scores in PFF children. These data further our understanding of the functional characteristics that lead to impaired QoL in PFF children. These findings will help guide the surveillance and management of children with this ubiquitous condition.

Static postural differences between neutral and flat feet in children with and without symptoms.

BACKGROUND: Flatfoot is a common variant of foot posture. Whilst usually benign, in some children flatfoot is accompanied by pain and functional complaints. Comparisons between the posture of asymptomatic and symptomatic flat feet are few. If a difference does exist, it may help understand symptoms and guide management. METHODS: This paper investigated differences in lower limb posture between neutral and flat feet with and without symptoms during standing using the multi-segment Oxford Foot Model. 97 children between five and 18years old were assessed by a physiotherapist; each foot was classified into one of four categories: asymptomatic neutral (n=88), asymptomatic mild flatfoot (n=47), asymptomatic flatfoot (n=29), or symptomatic flatfoot (n=30). For each child, Oxford Foot Model markers were applied, and mean values of 11-Euler angles at the foot, ankle, and knee joints during standing were calculated. Analysis of variance and post-hoc tests were used to identify differences between groups. FINDINGS: Hindfoot eversion was significantly increased (P<0.001) in children with asymptomatic and, to a greater extent, symptomatic flatfoot. The forefoot was significantly more abducted (P<0.001) in the symptomatic than asymptomatic groups, and in the flat than neutral group. The forefoot was more supinated relative to the hindfoot in the flatfoot groups (P=0.023), although post-hoc analysis did not identify specific group differences. INTERPRETATION: Hindfoot eversion and forefoot abduction were much greater in the symptomatic population. The differences in foot alignment may relate to the presence of symptoms.

A low-riding patella in posterior stabilised total knee replacements alters quadriceps' mechanical advantage, resulting in reduced knee flexion moments.

Abnormal in vivo Total Knee Replacement (TKR) kinetics is influenced by a range of factors, particularly by changes to the knee's geometric parameters such as the patellar tendon moment arm (PTMA). In this study, ground reaction force (GRF) measurements were combined with simultaneous fluoroscopic image measurements to investigate the relationship between abnormal TKR kinetics and geometric parameters. Nine Scorpio Cruciate Retaining (CR) TKR (Stryker, Newbury, UK), nine Scorpio Posterior Stabilized (PS) TKR and seven normal subjects performed a step-up activity on a forceplate in view of a fluoroscope. The TKR subjects were part of a larger ongoing randomised controlled trial. The maximum external knee flexion moment was 22.0% lower in the Scorpio PS group compared to the Scorpio CR group. No significant differences in PTMA were found between the groups. The Scorpio PS had a low-riding patella, with a 30.7% reduction in patellar height compared to the Scorpio CR. This was probably due to using a thick tibial insert after PCL release in the PS, and led to an 8° increase in patellar flexion angle which altered the patellar mechanism and reduced quadriceps' mechanical advantage. Consequently, PS subjects stepped-up more cautiously with a reduced knee flexion moment.

Improved quadriceps' mechanical advantage in single radius TKRs is not due to an increased patellar tendon moment arm.

Single femoral radius TKRs have been reported to improve quadriceps' mechanical advantage, leading to enhanced patient function. An increased patellar tendon moment arm (PTMA) has been cited as the main feature leading to improved quadriceps' mechanical advantage. However, these designs often incorporate a recessed trochlea which alters the patellar mechanism and may contribute to improved quadriceps' mechanical advantage. This study simultaneously measured the PTMA using two and three dimensional methods, as well as quadriceps forces (QF), patellofemoral kinematics and tibiofemoral kinematics in a motion analysis laboratory during an open chain leg extension activity. Six cadaveric knees were tested in the normal state and after implantation of three different single femoral radius TKR designs: cruciate retaining, posterior stabilised and rotating platform posterior stabilised (Stryker, Newbury, UK). QFs in the TKRs were between 15% and 20% lower than normal between 60° and 70° flexion. The increase in PTMA was insufficient to explain the reduced QF in the TKRs. The patellar flexion angle (PFA) of the TKRs was lower than normal at knee flexion angles greater than 50°, probably as a result of the recessed trochlea. A simple patellar model demonstrated that the reduced PFA may explain a large proportion of the reduction in QF after single radius TKR.

Experimental validation of a finite element model of a composite tibia.

Composite bones are synthetic models made to simulate the mechanical behaviour of human bones. Finite element (FE) models of composite bone can be used to evaluate new and modified designs of joint prostheses and fixation devices. The aim of the current study was to create an FE model of a composite tibia and to validate it against results obtained from a comprehensive set of experiments. For this, 17 strain rosettes were attached to a composite tibia (model 3101, Pacific Research Laboratories, Vashon, Washington, USA). Surface strains and displacements were measured under 13 loading conditions. Two FE models were created on the basis of computed tomography scans. The models differed from each other in the mesh and material properties assigned. The experiments were simulated on them and the results compared with experimental results. The more accurate model was selected on the basis of regression analysis. In general, experimental strain measurements were highly repeatable and compared well with published results. The more accurate model, in which the inner elements representing the foam were assigned isotropic material properties and the elements representing the epoxy layer were assigned transversely isotropic material properties, was able to simulate the mechanical behaviour of the tibia with acceptable accuracy. The regression line for all axial loads combined had a slope of 0.999, an intercept of -6.24 microstrain, and an R2 value of 0.962. The root mean square error as a percentage was 5 per cent.

How effective are added constraints in improving TKR kinematics?

Newer designs of total knee arthroplasty (TKA), through the use of added degrees of constraint, attempt to provide a "guided motion" to restore more normal and predictable kinematics. Two such design philosophies are the posterior stabilised (PS) using a cam-post and the medial pivot (MP) concepts. Knee kinematics of 12 patients with a PS TKA, 13 subjects with a MP TKA and 10 normal subjects were compared. For kinematic assessment, patients underwent fluoroscopic assessment of the knee during a step-up exercise and deep knee bend. Fluoroscopic images were corrected for distortion and assessed using 3D model fitting to determine relative 3D motion, and a 2D method to measure the patellar tendon angle (PTA) as function of knee flexion. For the PS design the cam-post mechanism engaged between 70 degrees and 100 degrees flexion. Between extension and 50 degrees there was forward motion of the contact points. Beyond 60 degrees both condyles rolled moved posteriorly. The majority of the external rotation of the femur occurred between 50 degrees and 80 degrees . The PTA was lower than normal in extension and higher than normal in flexion. The MP exhibited no anterior movement throughout the rage of motion. The medial condyle moved minimally. The lateral contact point moved posteriorly from extension to flexion. The femur rotated externally throughout the range of flexion analysed. The PTA was similar to normal from extension to mid flexion and then higher than normal beyond to high flexion. The PS design fails to fully restrain paradoxical anterior movement and although the cam engages, it does not contribute significantly to overall rollback. The MP knee does not show significant anterior movement, the medial pivot concept appears to achieve near normal kinematics from extension to 50 degrees of knee flexion. However, the results show that at high flexion this design does not achieve normal knee kinematics.

Prediction of the hip joint centre in adults, children, and patients with cerebral palsy based on magnetic resonance imaging.

The location of the hip joint centre (HJC) is required for calculations of hip moments, the location and orientation of the femur, and muscle lengths and lever arms. In clinical gait analysis, the HJC is normally estimated using regression equations based on normative data obtained from adult populations. There is limited relevant anthropometric data available for children, despite the fact that clinical gait analysis is predominantly used for the assessment of children with cerebral palsy. In this study, pelvic MRI scans were taken of eight adults (ages 23-40), 14 healthy children (ages 5-13) and 10 children with spastic diplegic cerebral palsy (ages 6-13). Relevant anatomical landmarks were located in the scans, and the HJC location in pelvic coordinates was found by fitting a sphere to points identified on the femoral head. The predictions of three common regression equations for HJC location were compared to those found directly from MRI. Maximum absolute errors of 31 mm were found in adults, 26 mm in children, and 31 mm in the cerebral palsy group. Results from regression analysis and leave-one-out cross-validation techniques on the MRI data suggested that the best predictors of HJC location were: pelvic depth for the antero-posterior direction; pelvic width and leg length for the supero-inferior direction; and pelvic depth and pelvic width for the medio-lateral direction. For single-variable regression, the exclusion of leg length and pelvic depth from the latter two regression equations is proposed. Regression equations could be generalised across adults, children and the cerebral palsy group.

Simultaneous in vitro measurement of patellofemoral kinematics and forces following Oxford medial unicompartmental knee replacement.

The Oxford medial unicompartmental knee replacement was designed to reproduce normal mobility and forces in the knee, but its detailed effect on the patellofemoral joint has not been studied previously. We have examined the effect on patellofemoral mechanics of the knee by simultaneously measuring patellofemoral kinematics and forces in 11 cadaver knee specimens in a supine leg-extension rig. Comparison was made between the intact normal knee and sequential unicompartmental and total knee replacement. Following medial mobile-bearing unicompartmental replacement in 11 knees, patellofemoral kinematics and forces did not change significantly from those in the intact knee across any measured parameter. In contrast, following posterior cruciate ligament retaining total knee replacement in eight knees, there were significant changes in patellofemoral movement and forces. The Oxford device appears to produce near-normal patellofemoral mechanics, which may partly explain the low incidence of complications with the extensor mechanism associated with clinical use.

Repeatability of a model for measuring multi-segment foot kinematics in children.

This study used a previously tested foot model and adapted it for use with children. A number of variations on this adapted model were implemented and tested for repeatability and accuracy on 15 healthy children on three occasions. These included redefinition of the long axes of the tibia and forefoot, assessment of the flexibility of the forefoot and evaluation of the variability of the wand marker on the heel for both static and dynamic trials. It was found that variations on the model produced only minimal changes in repeatability, the only significant change being elimination of the wand marker on the heel in the static trial, which reduced between-day variability of hindfoot motion in the transverse plane. However, some differences were evident in the mean values for all variations. Based on these results, the most accurate and appropriate version of the model is proposed, and average kinematic curves are presented based on the measurements from 14 healthy children.

Assessment of sub-division of plantar pressure measurement in children.

Methods for the measurement of plantar pressure are poorly defined particularly when describing sub-sections of the plantar surface of the foot in the presence of deformity. The aim of this study was to assess foot pressure measurement in healthy children, using an automatic technique of sub-area definition that has the potential for objective evaluation of treatment of foot deformity. Twelve healthy children were examined on three occasions. Plantar pressure data were collected and time synchronised with force plate and stereophotogrammetric data. The footprint was divided into five sub-sections by using the position of the markers on the foot at mid-stance projected onto the pressure footprint. Repeatability for peak pressure and peak force was assessed. Automatic sub-area definition based on marker placement was found to be reliable in healthy children. A comparison of results revealed that peak vertical force was a more consistent measure than peak pressure for each of the five sub-areas. This suggests that force may be a more appropriate measurement for outcome studies.

A constraint-based approach to modelling the mobility of the human knee joint.

A model of knee mobility able to predict the range and pattern of movement in the unloaded joint was proposed by Wilson et al. (J. Biomech. 31 (1998) 1127-1136). The articular surfaces in the lateral and medial compartments and isometric fascicles in three of the knee ligaments were represented as five constraints on motion between the femur and tibia in a single degree-of-freedom parallel spatial mechanism. The path of movement of the bones during passive flexion was found by solving the forward kinematics of the mechanism using an iterative method. The present paper shows that such a mechanism-based solution approach can lead to an underestimation of the flexion range. This is due to the mechanism reaching a 'stationary configuration' and 'locking'. A new, constraint-based approach to the solution of the model joint displacement is proposed. It avoids the representation of ligaments and articular surfaces by kinematically equivalent chains of one degree-of-freedom pairs which are prone to singularities. It relies instead on a numerical solution of five non-linear constraint equations to find the relative positions of the bones at a series of flexion angles. The method is successful both in its ability to predict motion through a physiological range and in its efficiency with a solution rate forty times faster than the original algorithm. The new approach may be extended to include more complex joint surface geometry, allowing a study of the effects of articular surface shape and ligament arrangement on joint kinematics.

Injury initiation and progression in the anterior cruciate ligament.

OBJECTIVE: To develop a theoretical model to identify mechanisms by which total and partial tears of the anterior cruciate ligament could occur. DESIGN: A sagittal-plane knee model was used to investigate anterior cruciate ligament injury due to excessive anterior tibial translation. The ligament was modelled as an ordered array of fibres linking femur and tibia. BACKGROUND: Despite years of research, the detailed biomechanics of anterior cruciate ligament injury is not well understood. METHODS: A "critical strain criterion" was used to identify the onset and progression of model ligament fibre disruption. The associated forces were also calculated. RESULTS: At low flexion angles (<20 degrees ), the posterior fibre of the model ligament failed first, and the tear progressed anteriorly through the ligament. At higher flexion angles, the anterior fibre failed first, and the tear progressed posteriorly. Near the flexion angle at which the progression of injury changed direction, all fibres failed at approximately the same anterior tibial translation. At all but very high flexion angles, the force supported by the injured ligament was maximum when initial fibre failure occurred; the force then decreased with increasing anterior tibial translation. CONCLUSIONS: Near (20 degrees ) flexion, all model anterior cruciate ligament fibres fail at approximately the same anterior tibial translation, implying that a partial ligament tear may be impossible in this flexion region. Relevance. This study provides insight into possible mechanisms of initiation and progression of anterior cruciate ligament injury. It suggests that a partial tear of the posterior half of the ligament may be difficult to detect clinically.

The components of passive knee movement are coupled to flexion angle.

Movement of the unloaded knee has been described in several studies by an "envelope of passive flexion", a description that does not describe or explain the widely reported coupling of internal tibial rotation to flexion. The objective of the current study was to show that the envelope of passive knee flexion can be reduced to a coupled path. Two hypotheses were tested: (1) in normal knees flexed passively, internal/external rotation, abduction/adduction and all three components of translation are coupled to flexion angle, and (2) the tibia rotates internally as the knee is flexed passively. Fifteen cadaver knees were flexed in a rig designed to apply minimal resistance to knee movement while three-dimensional kinematics of the femur relative to the tibia were measured with an electromagnetic tracking system. Each specimen displayed internal tibial rotation and posterior, proximal and medial displacement of a reference point with flexion, while a range of ab/adduction behaviour was observed. Mean absolute differences between the flexing and extending paths in normal specimens were under 2 and 0.2 degrees for internal/external tibial rotation and ab/adduction, respectively. Deviation from the movement path was resisted: when released after being displaced, the femur of each normal joint sprang back to its original position on the motion path. It was concluded that passive knee flexion can be described by a coupled path. Although the exact shape of the path is very sensitive to load and varies between knees, knee rotations and translations were always coupled to flexion, and internal tibial rotation with flexion was always observed.

A kinematic-freedom analysis of a flexed-knee-stance testing rig.

The Oxford Rig was designed for biomechanical testing of post-mortem human knee-joint specimens during simulated flexed-knee stance, such as occurs when riding a bicycle, rising from a chair, or climbing stairs. It has been asserted, but never proven, that the movements of the 'ankle' and 'hip' assemblies of the Oxford Rig combine to allow a knee specimen its natural six degrees-of-freedom of movement (6 d.o.f.). This paper investigates this claim mathematically using the general mobility criterion for spatial linkages and the basics of screw theory. It is shown that within the physiological range of knee-joint movement and the physical construction of the Rig, the knee specimen is allowed full spatial freedom (6 d.o.f.). The general approach used in this paper could also be applied to the analysis and, in particular, to the design of other rigs used for biomechanical testing of post-mortem human joint specimens.

Parameter sensitivity of a mathematical model of the anterior cruciate ligament.

This paper presents the results of an investigation into parameter sensitivity of a mathematical model of the human anterior cruciate ligament (ACL). The model ACL comprised a continuous array of fibres mapped between part-elliptical attachment areas on the femur and tibia. Relative motion of the two bones was controlled by a planar four-bar linkage. Parameter modifications were: (a) an alternative set of values for the coordinates of the four-bar linkage joints; (b) rotation of the attachment areas of the ligament by +/- 30 degrees; and (c) variation of some mechanical properties. The alternative four-bar linkage parameter set produced extremely large changes in ACL force values, up to 130 per cent. Rotating the tibial attachment changed forces by less than 20 per cent, whereas rotating the femoral attachment changed forces by up to 100 per cent. Altering the mechanical parameters produced the smallest differences in force, under 15 per cent. These results highlight the importance, when using a theoretical model, of establishing the values of the parameters defining the model as accurately as possible and of carrying out a parameter sensitivity study. From a clinical viewpoint, they also suggest that, when reconstructing a ruptured ACL, one of the most important considerations must be to position the femoral attachment of the graft as accurately as is feasible.

Cruciate ligament loading during isometric muscle contractions. A theoretical basis for rehabilitation.

A model of the knee in the sagittal plane was used to investigate the ligament forces resulting when an external load applied to the tibia resisted either extension or flexion of the knee under increasing isometric quadriceps or hamstrings contractions, respectively. An elementary mechanical analysis showed which ligament, the anterior or posterior cruciate, was loaded at a given flexion angle and known line of action of the external load. Ligament force, as a proportion of the external load, was also calculated. The results serve as guidelines for the design of injury-specific physical therapy techniques for use after cruciate ligament reconstruction.

Ligament forces at the knee during isometric quadriceps contractions.

A mathematical model of the knee in the sagittal plane was used to investigate the ligament forces resulting when a posteriorly directed external force, applied to the tibia, resists extension of the knee under increasing isometric quadriceps contractions. The model is based on simple geometric representations of the bones, ligaments and muscles at the knee. An elementary mechanical analysis was used to predict which ligament, the anterior or posterior cruciate, was loaded at a given flexion angle and known line of action of the external force. Ligament force, as a proportion of the external force, was calculated first assuming the ligaments to be represented by single, inextensible lines. Modelling the ligaments as continuous arrays of extensible fibres then showed that tibio-femoral translations and ligament forces increased non-linearly with increasing muscle forces and approached asymptotic values which depended on flexion angle. In most positions of the joint, the calculated asymptotic ligament force values were less than the reported ultimate strength of human ligament, despite quadriceps forces of over three times body weight. The possibility of these asymptotic values of ligament force may explain why, at certain flexion angles, large forces can be developed by the muscles at the knee without ligament rupture.