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Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks
Journal of Biomechanics ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Contents lists available at ScienceDirect
Journal of Biomechanics journal homepage: www.elsevier.com/locate/jbiomech www.JBiomech.com
Short communication
Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks Kentaro Takeda a,n, Takayuki Hasegawa a, Yoshimori Kiriyama b, Hideo Matsumoto c, Toshiro Otani d, Yoshiaki Toyama a, Takeo Nagura a,b a
Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan Department of Clinical Biomechanics, Keio University, Tokyo, Japan c Institute for Integrated Sports Medicine, Keio University, Tokyo, Japan d Faculty of Nursing and Medical Care, Keio University, Tokyo, Japan b
art ic l e i nf o
a b s t r a c t
Article history: Accepted 18 March 2014
The purpose of this study was to determine whether mechanical adaptations were present in patients with anterior cruciate ligament (ACL)-deficient knees during high-demand activities. Twenty-two subjects with unilateral ACL deficiency (11 males and 11 females, 19.6 months after injury) performed five different activities at a comfortable speed (level walking, ascending and descending steps, jogging, jogging to a 90-degree side cutting toward the opposite direction of the tested side). Three-dimensional knee kinematics for the ACL-deficient knees and uninjured contralateral knees were evaluated using the Point Cluster Technique. There was no significant difference in knee flexion angle, but an offset toward the knee in less valgus and more external tibial rotation was observed in the ACL-deficient knee. The tendency was more obvious in high demand motions, and a significant difference was clearly observed in the side cutting motions. These motion patterns, with the knee in less valgus and more external tibial rotation, are proposed to be an adaptive movement to avoid pivot shift dynamically, and reveal evidence in support of a dynamic adaptive motion occurring in ACL-deficient knees. & 2014 Published by Elsevier Ltd.
Keywords: Anterior cruciate ligament Knee kinematics Motion analysis Adaptation Pivot shift
1. Introduction Anterior cruciate ligament (ACL) injury is a major traumatic injury, and makes it difficult for athletes to continue or to begin sports activity participation without reconstruction surgery. Therefore, it is important to reveal how ACL deficiency affects joint mechanics and leads to functional disability. ACL injury leads to anterior–posterior instability and rotatory instability resulting in various adaptive movements. Decreased knee flexion in the stance phase of gait has been identified as an adaptive gait pattern in chronic ACL deficient patients (Rudolph et al., 1998; Torry et al., 2004). The lower flexion angles during stance in ACL deficient knees may be caused by a simultaneous contraction of the quadriceps femoris and hamstring muscles to achieve stability, and is known as the ‘stiffening knee strategy’. Also, abnormalities in ankle muscular activity patterns during gait have been reported in chronic ACL deficiency (Lindstrom et al., 2010). However, ACLdeficient knee axial plane biomechanics may be influenced by mechanics other than muscular activation. Abnormal tibial rotation during gait in the ACL-deficient knee has been reported n
Corresponding author. Tel.: þ 81 3 3353 1211; fax: þ81 3 3353 6597. E-mail address: [email protected] (K. Takeda).
(Andriacchi and Dyrby, 2005; Georgoulis et al., 2003; Georgoulis et al., 2005; Gao and Zheng, 2010; Zhang et al., 2003). Fuentes et al. (2011) described that ACL-deficient patients walked with a reduced internal rotation knee moment, and described the gait pattern as a ‘pivot shift avoidance gait’. The major problem for ACL-deficient patients is that they have limitations in or discomfort in performing more dynamic motions than gait. Therefore, understanding the influence of ACL deficiency in high-demand activities is essential for improving patient management. Several studies have investigated ACL-deficient knee mechanics during sports-related movements such as jogging and side step cutting or stair ascent or descent (Rudolph et al., 1998, 2000, 2001; Houck and Yack, 2003; Houck et al., 2005; 2007; Gao et al., 2012), but there is no study analyzing series of low demand and high demand tasks to reveal how the level of task affects the ACL deficient knee kinematics. The purpose of this study was to evaluate three-dimensional knee kinematics during low-demand and high-demand activities in ACL-deficient knees, and to determine how knee kinematics change in patients with ACL injury. We hypothesized that the alteration in knee kinematics caused by ACL injury would be more apparent during high-demand activities than during low-demand activities.
http://dx.doi.org/10.1016/j.jbiomech.2014.03.027 0021-9290/& 2014 Published by Elsevier Ltd.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
K. Takeda et al. / Journal of Biomechanics ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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2. Materials and methods
3.2. Knee varus/valgus angle (Fig. 2)
The subjects consisted of 22 patients (11 females and 11 males) who were diagnosed as unilateral ACL injury with manual clinical examination and MRI. All patients planned to have ACL reconstruction, and underwent the surgery after the examination for this study. Patients with other knee ligament injuries, meniscus injury with Mink grade 2 or more, moderate or severe patellofemoral and tibiofemoral joint osteoarthritic changes, a history of lower limb surgical procedures on either limb, and those with other neuromuscular disease were excluded. The mean subject age was 22 (range, 17–31) years old. The average time post-injury was 19.6 (range, 2–120) months. The activity level of subjects was determined by Tegner Activity Score and was 7.2 (range, 3–9) points in average. The research protocol was approved by our institutional review board and informed consent was obtained from each subject prior to enrollment. Subjects underwent motion analysis using six 120 Hz opto-electronic cameras (Pro-Reflex mcu120, Qualysis, Savedalen, Sweden), a multicomponent force plate at a synchronized frequency of 120 Hz (Type AM6110, Bertec, Columbus, OH, USA) and a control PC. The three-dimensional knee kinematics were obtained using the Point Cluster Technique (PCT) originally described by Andriacchi et al. (1998), in which a total of 21 light-reflective markers were placed on the iliac bone, thigh, shank and foot. A constant marker weighting was used to ensure that excessive non-rigid skin motion artifact has not occurred (Alexander and Andriacchi, 2001; Dyrby et al., 2004; Lathrop et al., 2011). Each subject performed five different activities at a self-selected speed with bare feet: level walking (WK), ascending and descending steps (SA, SD), jogging (JG), and jogging to a 90-degree side cutting to the opposite side of the tested side (JC) (Table 1). After practicing these activities, two successful trials of three trials were recorded for each motion. If all three trials were successful, the second and third trials were used. The contralateral side of the ACL-deficient knees were also evaluated as a control. Maximum vertical force (VF) and time length of the stance phase (TL) of the contralateral healthy knees were evaluated to determine the mechanical demand level of each activity. VF was calculated using inverse dynamics based on a local anatomical coordinate system placed on the tibia. VF and TL were statistically compared between the five activities using a single factor analysis of variance (ANOVA) with a significance level of p ¼ 0.05. Knee flexion, valgus and tibial rotation angles with respect to the femur were evaluated in each subject. The data lengths were normalized by the time length of the stance phase, which is defined from 0% stance (the foot touched the force plate) to 100% stance (the foot lifted off of the plate), and the kinematics were analyzed at 5% intervals. A 5% value was chosen to detect time-dependent change due to the ACL deficiency during the activities. The average knee flexion, valgus and tibial rotation angles were compared between the ACL-deficient side and the healthy side. A repeated-measures ANOVA with two within-subjects factors was used to test the hypotheses that these kinematic parameters were different between ACL-deficient and healthy contralateral knees. The two factors used were the knee status (ACL-deficient vs. contralateral) and time point (each 5% stance phase). A Bonferroni correction level of 0.017 was used in the ANOVA to account for the analysis of three kinematic parameters (flexion/extension, varus/valgus and internal /external rotation of tibia).
Overall, ACL-deficient knees tended to have a smaller valgus angle than the contralateral knees. The difference became more apparent during cutting activities. The valgus angle was an average of 51 smaller in ACL-deficient knees during 901 cutting activities, and this difference was significant from just before the initial stance phase (p¼ 0.006) and from 10% to 15% of the stance phase (p ¼0.015, 0.016). There was no significant difference in knee varus/valgus angle during the other activities.
3. Results Mechanical demands during jogging and side cutting were greater than other activities as the greater forces were applied to the knee in a shorter period during the two activities. 3.1. Knee flexion/extension angle (Fig. 1) There were no differences in knee flexion-extension patterns between ACL-deficient and the contralateral knees during the five activities.
3.3. Tibial external/internal rotation (Fig. 3) ACL-deficient knees tended to maintain more tibial external rotation during all activities when compared to the contralateral knees. There was significantly less internal tibial rotation (more external tibial rotation) during cutting maneuver than on the healthy side at 15% of stance. The average difference in tibial rotation at that point was 4.61 (p ¼0.017). The peak internal rotation occurred at the end of the stance phase, and a significant difference was observed from 95% to 100% stance and just after the foot lifted off of the plate, with a difference of 6.01 (p ¼0.013– 0.016).
4. Discussion Our results suggest that alteration in three-dimensional knee kinematics due to ACL deficiency becomes more obvious during the high-demand activities. ACL-deficient knees had a tendency to show less valgus and more tibial external rotation during walking, stair activities and straight line jogging, and the differences were significant during cutting activities. Side cutting activities are reported to apply greater torque to the knee than level walking or jogging. Houck et al. (2006) reported there were greater knee abduction (valgus) moments in side step cutting than walking. Besier et al. (2001) indicated that greater knee internal rotation moment occurred during side cutting than walking or running in healthy subjects. The reduction in the knee valgus angle during higher demand activities such as side cutting suggests that ACL-deficient patients tend to maintain the injured knee in a less abducted position to avoid greater valgus torque during the activity. Since there is greater mechanical load during side cutting than other activities, the load on the knee and the high speed motion associated with the tibial rotation caused an external rotation offset referred to the healthy side likely to avoid internal rotation moment. This occurred even though the amount of rotation angles was not different between activities. The sagittal knee mechanics are associated with muscle activation in ACL deficient patients (Rudolph et al., 1998; Torry et al., 2004; Lindstrom et al., 2010), while the axial mechanics are more mechanically determined. This is because of the anatomy of the
Table 1 Detailed descriptions of activities in the current study. Level walking (WK)
Walked toward the force plate at a self-selected speed and struck the force plate with the tested side foot.
Step ascent (SA)
A 21.5 cm, 32 cm deep step was placed on top of the center of the force plate next to a 43 cm tall box. The subject stood facing the 21.5-cm-tall step, then placed the tested foot on top of the 21.5 cm tall step. Next the subject placed the opposite side foot on top of the 43 cm tall box adjoining the 21.5 cm step.
Step descent (SD)
A 21.5 cm, 32 cm deep step was placed on top of the center of the force plate next to a 43 cm tall box. The subject stood on the 43-cm-tall box, stepped down onto the step with the tested side leg first and stepped down onto the ground with the opposite side leg.
Jogging (JG)
Jogged forward and struck the plate with the tested side foot at a self-selected speed.
Jogging to cutting (JC) Jogged forward to the force plate, struck the force plate with the tested side foot and jumped to the opposite side of the tested foot facing forward at approximately 901.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
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Fig. 1. Changes in the knee flexion angle (average of all subjects) during each activity. Zero percent indicated that the tested side foot made contact with the force plate, and 100% indicated that the tested side foot lifted off from the force plate along the X-axis. Stance indicated that the foot was in contact with the plate, and swing indicated that the foot was not in contact with the plate. No significant difference was observed in the knee flexion angle during any activity. 10% intervals were used in the graphs to improve visibility.
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Fig. 2. Changes in the knee varus/valgus angle (average of all subjects) during each activity. Zero percent indicated that the tested side foot made contact with the force plate and 100% indicated that the tested side foot lifted off from the force plate along the X-axis. Stance indicated that the foot was in contact with the plate, and swing indicated that the foot was not in contact with the plate. The knee valgus angle was less in the ACL-deficient knee. Significant differences were observed from just before the initial stance phase and from 10% to 15% of stance during JC (np o 0.017). 10% intervals were used in the graphs to improve visibility.
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knee extensors and flexors that has a dominant function to stabilize the knee in the sagittal plane more so than in the axial plane. The results of our study indicate that the influence of the ACL deficiency was more apparent in the axial plane than the sagittal plane (Figs. 1 and 3). We believe the motion pattern of ACL-deficient knees is considered to be a dynamic adaptation to avoid the pivot shift during athletic movement. This phenomenon occurs with anterolateral subluxation of the tibial plateau under knee valgus torque when the tibia rotates internally with respect to the femur in slight knee flexion position while the center of knee rotation shifts to the medial collateral ligament from the ACL (Matsumoto, 1990). This adaptation functions to limit physiological movement of the knee and makes it difficult for ACL-deficient patients to return to sports activities without reconstructive surgery. Discrepancies in reported three-dimensional knee kinematics for ACL-deficient knees have been reported in the literature. In particular, both increased internal and external tibial rotation in the ACL-deficient knee during gait have been reported (Andriacchi and Dyrby, 2005; Georgoulis et al., 2003; Georgoulis et al., 2005; Gao and Zheng, 2010). These variances may be due to differences in subject background, sample size (male-female ratio), testing protocol (with or without shoes) or the method used to determine knee kinematics. For example, increased internal tibial rotation, which is in contrast to our results, was reported by Andriacchi and Dyrby (2005) who used an identical method (PCT). However, the subjects in their study had an average time post-injury of 127 months, and were tested with their shoes on. These differences in subject background and design likely affected the axial plane knee kinematics. One of the limitations was the use of the contralateral knee as a control rather than a healthy knee, as the kinematics of the contralateral knee may be affected by the ACL injury. However, the contralateral knee is universally used as a control for quantitative knee laxity measurements such as the KT-1000, since joint laxity has substantial inter-subject variation. Therefore, kinematics associated with laxity changes may be best evaluated with an intra-subject control (Scanlan et al., 2010; Daniel et al., 1985). Measurement errors due to the skin artifact have been reported, especially in the axial rotation in early stance phase during activities that involve landing and change of direction (Benoit et al., 2006; Li et al., 2012; Miranda et al., 2013). However, the difference in the axial rotation during cutting was identified in late stance where the artifact was shown to be less (Benoit et al., 2006). In addition, type of marker set and number of markers affect the accuracy, while use of multiple markers (up to 37 in a limb) is shown to provide better accuracy (Gao et al., 2012). The PCT is capturing consistent movement patterns however definitive comparison between point-cluster and a gold standard for walking or cutting maneuvers would be needed in the future.
5. Conclusion and clinical relevance
Fig. 3. Changes in tibial rotation as related to the femur (average of all subjects) during each activity. Zero percent indicated that the tested side foot contacted the force plate and 100% indicated that the tested side foot lifted off from the force plate along the X-axis. Stance indicated that the foot was in contact with the plate, and swing indicated that the foot was not in contact with the plate. The tibia rotated more externally in the ACL-deficient knee. A significant difference was observed at 15% and from 95% to 100% of stance and just after the foot lifted up from the plate during JC (npo 0.017). 10% intervals were used in the graphs to improve visibility.
The three-dimensional kinematics of the ACL-deficient knee showed less adaptive movement during low-demand activity and clearly showed adaptive movement during high-demand activity. The adaptive movements included maintaining the knee in less valgus and more external tibial rotation, which is likely to avoid the pivot shift. The movement pattern of the ACL-deficient knee is proposed as a dynamic adaptive motion, and the altered knee kinematics may limit patient's ability to return to their original sports activity and can be the reason to require reconstructive surgery.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
K. Takeda et al. / Journal of Biomechanics ∎ (∎∎∎∎) ∎∎∎–∎∎∎
6. Potential conflict of interest statement
We have received no funding or sponsorship for this study, including funds or materials (e.g., surgical supplies, specimens).
We have not, in the past five years, received the following from
an organization that may in any way gain or lose financially from the results of our study: Reimbursement for attending a symposium. A fee for speaking or for organizing an educational program. Funds for research. Funds for one of your employees. Royalties or fees for consulting. We have not, in the past five years, been employed by an organization that may in any way gain or lose financially from the results of our study. We hold no stocks or bonds in an organization that may in any way gain or lose financially from the results of our study. (This excludes stocks or bonds that may be held in mutual funds.) We do not have any other potential financial conflict of interest. None of our spouses, parents, children, or siblings has a relationship as described above in questions one through five.
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Gao, B., Zheng, N., 2010. Alterations in three-dimensional joint kinematics of anterior cruciate ligament-deficient and -reconstructed knees during walking. Clin. Biomech. 25, 222–229. Gao, B., Cordova, M.L., Zheng, N.N., 2012. Three-dimensional joint kinematics of ACL-deficient and ACL-reconstructed knees during stair ascent and descent. Hum. Mov. Sci. 31, 222–235. Georgoulis, A.D., Papadonikolakis, A., Papageorgiou, C.D., 2003. Three-dimensional tibiofemoral kinematics of the anterior cruciate deficient and reconstructed knee during walking. Am. J. Sports Med. 31, 75–79. Georgoulis, A.D., Ristanis, S., Moraiti, C., Mitsou, A., Bernard, M., Stergiou, N., 2005. Three-dimensional kinematics of the tibiofemoral joint in ACL-deficient and reconstructed patients shows increased tibial rotation. Oper. Tech. Orthop. 15, 49–56. Houck, J.R., Duncan, A., Haven, K.E.D., 2005. Knee and hip angle and moment adaptations during cutting tasks in subjects with anterior cruciate ligament deficiency classified as noncopers. J. Orthop. Sports Phys. Ther. 35, 531–540. Houck, J.R., Duncan, A., Haven, K.E.D., 2006. Comparison of frontal plane trunk kinematics and hip and knee moments during anticipated and unanticipated walking and side step cutting tasks. Gait Posture 24, 314–322. Houck, J.R., Yack, H.J., 2003. Associations of knee angles, moments and function among subjects that are healthy and anterior cruciate ligament deficient (ACLD) during straight ahead and crossover cutting activities. Gait Posture 18, 126–138. Houck, J.R., De Haven, K.E., Maloney, M., 2007. Influence of anticipation on movement patterns in subjects with ACL deficiency classified as noncopers. J. Orthop. Sports Phys. Ther. 37, 56–64. Lathrop, R.L., Chaudhari, A.M., Siston, R.A., 2011. Comparative assessment of bone pose estimation using Point Cluster Technique and OpenSim. J. Biomech. Eng. 133, 114503. Lindstrom, M., Fellander-Tsai, L., Wredmark, T., Henriksson, M., 2010. Adaptations of gait and muscle activation in chronic ACL deficiency. Knee Surg. Sports Traumatol. Arthrosc. 18, 106–114. Li, K., Zheng, L., Tashman, S., Zhang, X., 2012. The inaccuracy of surface-measured model-derived tibiofemoral kinematics. J. Biomech. 45, 2719–2723. Matsumoto, H., 1990. Mechanism of the pivot shift. J. Bone Jt. Surg. Br. 72, 816–821. Miranda, D.L., Rainbow, M.J., Crisco, J.J., Fleming, B.C., 2013. Kinematic differences between optical motion capture and biplanar videoradiography during a jump– cut maneuver. J. Biomech. 46, 567–573. Rudolph, K.S., Axe, M.J., Buchanan, T.S., Scholz, J.P., Snyder-Mackler, L., 2001. Dynamic stability in the anterior cruciate ligament deficient knee. Knee Surg. Sports Traumatol. Arthrosc. 9, 62–71. Rudolph, K.S., Axe, M.J., Snyder-Mackler, L., 2000. Dynamic stability after ACL injury: who can hop? Knee Surg. Sports Traumatol. Arthrosc. 8, 262–269. Rudolph, K.S., Eastlack, M.E., Axe, M.J., Snyder-Mackler, L., 1998. Movement patterns after anterior cruciate ligament injury: a comparison of patients who compensate well for the injury and those who require operative stabilization. J. Electromyogr. Kinesiol. 8, 349–362. Scanlan, S.F., Chaudhari, A.M.W., Dyrby, C.O., Andriacchi, T.P., 2010. Differences in tibial rotation during walking in ACL reconstructed and healthy contralateral knees. J. Biomech. 43, 1817–1822. Torry, M.R., Decker, M.J., Ellis, H.B., Shelburne, K.B., Strett, W.I., Steadman, J.R., 2004. Mechanisms of compensating for anterior cruciate ligament deficiency during gait. Med. Sci. Sports Exerc. 36, 1403–1412. Zhang, L., Shiavi, R.G., Limbird, T.J., Minorik, J.M., 2003. Six degrees-of-freedom kinematics of ACL deficient knees during locomotion – compensatory mechanism. Gait Posture 17, 34–42.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
Contents lists available at ScienceDirect
Journal of Biomechanics journal homepage: www.elsevier.com/locate/jbiomech www.JBiomech.com
Short communication
Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks Kentaro Takeda a,n, Takayuki Hasegawa a, Yoshimori Kiriyama b, Hideo Matsumoto c, Toshiro Otani d, Yoshiaki Toyama a, Takeo Nagura a,b a
Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan Department of Clinical Biomechanics, Keio University, Tokyo, Japan c Institute for Integrated Sports Medicine, Keio University, Tokyo, Japan d Faculty of Nursing and Medical Care, Keio University, Tokyo, Japan b
art ic l e i nf o
a b s t r a c t
Article history: Accepted 18 March 2014
The purpose of this study was to determine whether mechanical adaptations were present in patients with anterior cruciate ligament (ACL)-deficient knees during high-demand activities. Twenty-two subjects with unilateral ACL deficiency (11 males and 11 females, 19.6 months after injury) performed five different activities at a comfortable speed (level walking, ascending and descending steps, jogging, jogging to a 90-degree side cutting toward the opposite direction of the tested side). Three-dimensional knee kinematics for the ACL-deficient knees and uninjured contralateral knees were evaluated using the Point Cluster Technique. There was no significant difference in knee flexion angle, but an offset toward the knee in less valgus and more external tibial rotation was observed in the ACL-deficient knee. The tendency was more obvious in high demand motions, and a significant difference was clearly observed in the side cutting motions. These motion patterns, with the knee in less valgus and more external tibial rotation, are proposed to be an adaptive movement to avoid pivot shift dynamically, and reveal evidence in support of a dynamic adaptive motion occurring in ACL-deficient knees. & 2014 Published by Elsevier Ltd.
Keywords: Anterior cruciate ligament Knee kinematics Motion analysis Adaptation Pivot shift
1. Introduction Anterior cruciate ligament (ACL) injury is a major traumatic injury, and makes it difficult for athletes to continue or to begin sports activity participation without reconstruction surgery. Therefore, it is important to reveal how ACL deficiency affects joint mechanics and leads to functional disability. ACL injury leads to anterior–posterior instability and rotatory instability resulting in various adaptive movements. Decreased knee flexion in the stance phase of gait has been identified as an adaptive gait pattern in chronic ACL deficient patients (Rudolph et al., 1998; Torry et al., 2004). The lower flexion angles during stance in ACL deficient knees may be caused by a simultaneous contraction of the quadriceps femoris and hamstring muscles to achieve stability, and is known as the ‘stiffening knee strategy’. Also, abnormalities in ankle muscular activity patterns during gait have been reported in chronic ACL deficiency (Lindstrom et al., 2010). However, ACLdeficient knee axial plane biomechanics may be influenced by mechanics other than muscular activation. Abnormal tibial rotation during gait in the ACL-deficient knee has been reported n
Corresponding author. Tel.: þ 81 3 3353 1211; fax: þ81 3 3353 6597. E-mail address: [email protected] (K. Takeda).
(Andriacchi and Dyrby, 2005; Georgoulis et al., 2003; Georgoulis et al., 2005; Gao and Zheng, 2010; Zhang et al., 2003). Fuentes et al. (2011) described that ACL-deficient patients walked with a reduced internal rotation knee moment, and described the gait pattern as a ‘pivot shift avoidance gait’. The major problem for ACL-deficient patients is that they have limitations in or discomfort in performing more dynamic motions than gait. Therefore, understanding the influence of ACL deficiency in high-demand activities is essential for improving patient management. Several studies have investigated ACL-deficient knee mechanics during sports-related movements such as jogging and side step cutting or stair ascent or descent (Rudolph et al., 1998, 2000, 2001; Houck and Yack, 2003; Houck et al., 2005; 2007; Gao et al., 2012), but there is no study analyzing series of low demand and high demand tasks to reveal how the level of task affects the ACL deficient knee kinematics. The purpose of this study was to evaluate three-dimensional knee kinematics during low-demand and high-demand activities in ACL-deficient knees, and to determine how knee kinematics change in patients with ACL injury. We hypothesized that the alteration in knee kinematics caused by ACL injury would be more apparent during high-demand activities than during low-demand activities.
http://dx.doi.org/10.1016/j.jbiomech.2014.03.027 0021-9290/& 2014 Published by Elsevier Ltd.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
K. Takeda et al. / Journal of Biomechanics ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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2. Materials and methods
3.2. Knee varus/valgus angle (Fig. 2)
The subjects consisted of 22 patients (11 females and 11 males) who were diagnosed as unilateral ACL injury with manual clinical examination and MRI. All patients planned to have ACL reconstruction, and underwent the surgery after the examination for this study. Patients with other knee ligament injuries, meniscus injury with Mink grade 2 or more, moderate or severe patellofemoral and tibiofemoral joint osteoarthritic changes, a history of lower limb surgical procedures on either limb, and those with other neuromuscular disease were excluded. The mean subject age was 22 (range, 17–31) years old. The average time post-injury was 19.6 (range, 2–120) months. The activity level of subjects was determined by Tegner Activity Score and was 7.2 (range, 3–9) points in average. The research protocol was approved by our institutional review board and informed consent was obtained from each subject prior to enrollment. Subjects underwent motion analysis using six 120 Hz opto-electronic cameras (Pro-Reflex mcu120, Qualysis, Savedalen, Sweden), a multicomponent force plate at a synchronized frequency of 120 Hz (Type AM6110, Bertec, Columbus, OH, USA) and a control PC. The three-dimensional knee kinematics were obtained using the Point Cluster Technique (PCT) originally described by Andriacchi et al. (1998), in which a total of 21 light-reflective markers were placed on the iliac bone, thigh, shank and foot. A constant marker weighting was used to ensure that excessive non-rigid skin motion artifact has not occurred (Alexander and Andriacchi, 2001; Dyrby et al., 2004; Lathrop et al., 2011). Each subject performed five different activities at a self-selected speed with bare feet: level walking (WK), ascending and descending steps (SA, SD), jogging (JG), and jogging to a 90-degree side cutting to the opposite side of the tested side (JC) (Table 1). After practicing these activities, two successful trials of three trials were recorded for each motion. If all three trials were successful, the second and third trials were used. The contralateral side of the ACL-deficient knees were also evaluated as a control. Maximum vertical force (VF) and time length of the stance phase (TL) of the contralateral healthy knees were evaluated to determine the mechanical demand level of each activity. VF was calculated using inverse dynamics based on a local anatomical coordinate system placed on the tibia. VF and TL were statistically compared between the five activities using a single factor analysis of variance (ANOVA) with a significance level of p ¼ 0.05. Knee flexion, valgus and tibial rotation angles with respect to the femur were evaluated in each subject. The data lengths were normalized by the time length of the stance phase, which is defined from 0% stance (the foot touched the force plate) to 100% stance (the foot lifted off of the plate), and the kinematics were analyzed at 5% intervals. A 5% value was chosen to detect time-dependent change due to the ACL deficiency during the activities. The average knee flexion, valgus and tibial rotation angles were compared between the ACL-deficient side and the healthy side. A repeated-measures ANOVA with two within-subjects factors was used to test the hypotheses that these kinematic parameters were different between ACL-deficient and healthy contralateral knees. The two factors used were the knee status (ACL-deficient vs. contralateral) and time point (each 5% stance phase). A Bonferroni correction level of 0.017 was used in the ANOVA to account for the analysis of three kinematic parameters (flexion/extension, varus/valgus and internal /external rotation of tibia).
Overall, ACL-deficient knees tended to have a smaller valgus angle than the contralateral knees. The difference became more apparent during cutting activities. The valgus angle was an average of 51 smaller in ACL-deficient knees during 901 cutting activities, and this difference was significant from just before the initial stance phase (p¼ 0.006) and from 10% to 15% of the stance phase (p ¼0.015, 0.016). There was no significant difference in knee varus/valgus angle during the other activities.
3. Results Mechanical demands during jogging and side cutting were greater than other activities as the greater forces were applied to the knee in a shorter period during the two activities. 3.1. Knee flexion/extension angle (Fig. 1) There were no differences in knee flexion-extension patterns between ACL-deficient and the contralateral knees during the five activities.
3.3. Tibial external/internal rotation (Fig. 3) ACL-deficient knees tended to maintain more tibial external rotation during all activities when compared to the contralateral knees. There was significantly less internal tibial rotation (more external tibial rotation) during cutting maneuver than on the healthy side at 15% of stance. The average difference in tibial rotation at that point was 4.61 (p ¼0.017). The peak internal rotation occurred at the end of the stance phase, and a significant difference was observed from 95% to 100% stance and just after the foot lifted off of the plate, with a difference of 6.01 (p ¼0.013– 0.016).
4. Discussion Our results suggest that alteration in three-dimensional knee kinematics due to ACL deficiency becomes more obvious during the high-demand activities. ACL-deficient knees had a tendency to show less valgus and more tibial external rotation during walking, stair activities and straight line jogging, and the differences were significant during cutting activities. Side cutting activities are reported to apply greater torque to the knee than level walking or jogging. Houck et al. (2006) reported there were greater knee abduction (valgus) moments in side step cutting than walking. Besier et al. (2001) indicated that greater knee internal rotation moment occurred during side cutting than walking or running in healthy subjects. The reduction in the knee valgus angle during higher demand activities such as side cutting suggests that ACL-deficient patients tend to maintain the injured knee in a less abducted position to avoid greater valgus torque during the activity. Since there is greater mechanical load during side cutting than other activities, the load on the knee and the high speed motion associated with the tibial rotation caused an external rotation offset referred to the healthy side likely to avoid internal rotation moment. This occurred even though the amount of rotation angles was not different between activities. The sagittal knee mechanics are associated with muscle activation in ACL deficient patients (Rudolph et al., 1998; Torry et al., 2004; Lindstrom et al., 2010), while the axial mechanics are more mechanically determined. This is because of the anatomy of the
Table 1 Detailed descriptions of activities in the current study. Level walking (WK)
Walked toward the force plate at a self-selected speed and struck the force plate with the tested side foot.
Step ascent (SA)
A 21.5 cm, 32 cm deep step was placed on top of the center of the force plate next to a 43 cm tall box. The subject stood facing the 21.5-cm-tall step, then placed the tested foot on top of the 21.5 cm tall step. Next the subject placed the opposite side foot on top of the 43 cm tall box adjoining the 21.5 cm step.
Step descent (SD)
A 21.5 cm, 32 cm deep step was placed on top of the center of the force plate next to a 43 cm tall box. The subject stood on the 43-cm-tall box, stepped down onto the step with the tested side leg first and stepped down onto the ground with the opposite side leg.
Jogging (JG)
Jogged forward and struck the plate with the tested side foot at a self-selected speed.
Jogging to cutting (JC) Jogged forward to the force plate, struck the force plate with the tested side foot and jumped to the opposite side of the tested foot facing forward at approximately 901.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
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Fig. 1. Changes in the knee flexion angle (average of all subjects) during each activity. Zero percent indicated that the tested side foot made contact with the force plate, and 100% indicated that the tested side foot lifted off from the force plate along the X-axis. Stance indicated that the foot was in contact with the plate, and swing indicated that the foot was not in contact with the plate. No significant difference was observed in the knee flexion angle during any activity. 10% intervals were used in the graphs to improve visibility.
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Fig. 2. Changes in the knee varus/valgus angle (average of all subjects) during each activity. Zero percent indicated that the tested side foot made contact with the force plate and 100% indicated that the tested side foot lifted off from the force plate along the X-axis. Stance indicated that the foot was in contact with the plate, and swing indicated that the foot was not in contact with the plate. The knee valgus angle was less in the ACL-deficient knee. Significant differences were observed from just before the initial stance phase and from 10% to 15% of stance during JC (np o 0.017). 10% intervals were used in the graphs to improve visibility.
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knee extensors and flexors that has a dominant function to stabilize the knee in the sagittal plane more so than in the axial plane. The results of our study indicate that the influence of the ACL deficiency was more apparent in the axial plane than the sagittal plane (Figs. 1 and 3). We believe the motion pattern of ACL-deficient knees is considered to be a dynamic adaptation to avoid the pivot shift during athletic movement. This phenomenon occurs with anterolateral subluxation of the tibial plateau under knee valgus torque when the tibia rotates internally with respect to the femur in slight knee flexion position while the center of knee rotation shifts to the medial collateral ligament from the ACL (Matsumoto, 1990). This adaptation functions to limit physiological movement of the knee and makes it difficult for ACL-deficient patients to return to sports activities without reconstructive surgery. Discrepancies in reported three-dimensional knee kinematics for ACL-deficient knees have been reported in the literature. In particular, both increased internal and external tibial rotation in the ACL-deficient knee during gait have been reported (Andriacchi and Dyrby, 2005; Georgoulis et al., 2003; Georgoulis et al., 2005; Gao and Zheng, 2010). These variances may be due to differences in subject background, sample size (male-female ratio), testing protocol (with or without shoes) or the method used to determine knee kinematics. For example, increased internal tibial rotation, which is in contrast to our results, was reported by Andriacchi and Dyrby (2005) who used an identical method (PCT). However, the subjects in their study had an average time post-injury of 127 months, and were tested with their shoes on. These differences in subject background and design likely affected the axial plane knee kinematics. One of the limitations was the use of the contralateral knee as a control rather than a healthy knee, as the kinematics of the contralateral knee may be affected by the ACL injury. However, the contralateral knee is universally used as a control for quantitative knee laxity measurements such as the KT-1000, since joint laxity has substantial inter-subject variation. Therefore, kinematics associated with laxity changes may be best evaluated with an intra-subject control (Scanlan et al., 2010; Daniel et al., 1985). Measurement errors due to the skin artifact have been reported, especially in the axial rotation in early stance phase during activities that involve landing and change of direction (Benoit et al., 2006; Li et al., 2012; Miranda et al., 2013). However, the difference in the axial rotation during cutting was identified in late stance where the artifact was shown to be less (Benoit et al., 2006). In addition, type of marker set and number of markers affect the accuracy, while use of multiple markers (up to 37 in a limb) is shown to provide better accuracy (Gao et al., 2012). The PCT is capturing consistent movement patterns however definitive comparison between point-cluster and a gold standard for walking or cutting maneuvers would be needed in the future.
5. Conclusion and clinical relevance
Fig. 3. Changes in tibial rotation as related to the femur (average of all subjects) during each activity. Zero percent indicated that the tested side foot contacted the force plate and 100% indicated that the tested side foot lifted off from the force plate along the X-axis. Stance indicated that the foot was in contact with the plate, and swing indicated that the foot was not in contact with the plate. The tibia rotated more externally in the ACL-deficient knee. A significant difference was observed at 15% and from 95% to 100% of stance and just after the foot lifted up from the plate during JC (npo 0.017). 10% intervals were used in the graphs to improve visibility.
The three-dimensional kinematics of the ACL-deficient knee showed less adaptive movement during low-demand activity and clearly showed adaptive movement during high-demand activity. The adaptive movements included maintaining the knee in less valgus and more external tibial rotation, which is likely to avoid the pivot shift. The movement pattern of the ACL-deficient knee is proposed as a dynamic adaptive motion, and the altered knee kinematics may limit patient's ability to return to their original sports activity and can be the reason to require reconstructive surgery.
Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i
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6. Potential conflict of interest statement
We have received no funding or sponsorship for this study, including funds or materials (e.g., surgical supplies, specimens).
We have not, in the past five years, received the following from
an organization that may in any way gain or lose financially from the results of our study: Reimbursement for attending a symposium. A fee for speaking or for organizing an educational program. Funds for research. Funds for one of your employees. Royalties or fees for consulting. We have not, in the past five years, been employed by an organization that may in any way gain or lose financially from the results of our study. We hold no stocks or bonds in an organization that may in any way gain or lose financially from the results of our study. (This excludes stocks or bonds that may be held in mutual funds.) We do not have any other potential financial conflict of interest. None of our spouses, parents, children, or siblings has a relationship as described above in questions one through five.
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Please cite this article as: Takeda, K., et al., Kinematic motion of the anterior cruciate ligament deficient knee during functionally high and low demanding tasks. Journal of Biomechanics (2014), http://dx.doi.org/10.1016/j.jbiomech.2014.03.027i