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Knee adduction moment and medial knee contact force during gait in older people
Accepted Manuscript Title: Knee adduction moment and medial knee contact force during gait in older people Author: Shinya Ogaya Hisashi Naito Akira Iwata Yumi Higuchi Satoshi Fuchioka Masao Tanaka PII: DOI: Reference:
S0966-6362(14)00496-2 http://dx.doi.org/doi:10.1016/j.gaitpost.2014.04.205 GAIPOS 4201
To appear in:
Gait & Posture
Received date: Revised date: Accepted date:
19-9-2013 11-4-2014 27-4-2014
Please cite this article as: Ogaya Shinya, Naito Hisashi, Iwata Akira, Higuchi Yumi, Fuchioka Satoshi, Tanaka Masao.Knee adduction moment and medial knee contact force during gait in older people.Gait and Posture http://dx.doi.org/10.1016/j.gaitpost.2014.04.205 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Knee adduction moment and medial knee contact forceduring gait inolder people
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Author:Shinya Ogaya1,2),Hisashi Naito2),Akira Iwata1), Yumi Higuchi1),
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Satoshi Fuchioka1), Masao Tanaka2)
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1) Division of Physical Therapy, Department of Comprehensive Rehabilitation, Osaka
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Prefecture University, Osaka, Japan
3-7-30, Habikino,Habikino-shi, Osaka, 583-8555, Japan
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Tel : +81-72-9502111Fax : +81-72-9502130E-mail : [email protected]
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2) Division of Bioengineering, Department of Mechanical Science and Bioengineering,
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Graduate School of Engineering Science, Osaka University 1-3 Machikaneyama, Toyonaka, Osaka, 560-8531,Japan
Highlights
We examine the relationship between medial knee contact force and knee adduction moment during gait in older people
We calculated the medial contact force using musculo-skeletal based-simulation analysis for 122 older people.
The medial knee contact force moderately correlated to the external adduction moment as well as the extension moment.
The medial knee contact force could be predicted by both adduction and extension moment.
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Abstract
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External knee adduction moment has been studied as a surrogate for
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medial knee contact force.However, it is not known whether adduction
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moment is a rational measure for predicting medial knee contact force. The aim of this study was to investigate the correlation between knee adduction
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moment and medial knee contact forceinolderpeople, using musculo-skeletal
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simulation analysis. One hundred and twenty-two healthy oldersubjects participated in this study. Knee moment and medial knee contact force were
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calculated based on inverse dynamics analysis of normal walking. Muscle force and joint reaction force were used to determine the medial knee contact force during stance phase. The results showed that the maximum medial knee contact force was moderately correlated to the maximum knee adduction (r=0.59) as well as the maximum extension moment (r=0.60). The first peak of medial knee contact force had a significant strong correlation with the first peak of adduction moment and a moderate correlation with the maximum flexion moment. The second peak of medial knee contact force had a significant moderate correlation with both the second peak of adduction
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and the maximum extension moment. These results implied that the maximum adduction moment value could be used, to some extent,as a
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measure of the maximum medial knee contact force.
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Keywords:
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adduction moment, medial knee contact force, gait, simulation, older people
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Introduction
Osteoarthritis (OA) is a major joint diseasethat restricts activities of daily
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living. The risk of developing OA increases with age. Adverse mechanical loading of the knee, such as repetitive and high-magnitude joint load, is believed to contribute to the development of knee OA 1. Knee OA is developed predominantly in the medial compartment of the tibiofemoral joint
2.
Measurement of medial knee contact force, i.e.,contact force on the medial compartment of the tibio-femoral joint, would be valuable for identifying the risk of knee OA development. However,thus far, it has been impossible to measure medial knee contact force in a noninvasive manner, andthe number of studies on medial knee contact force measurement is limited 3-5.
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It is considered that the maximum external knee adduction moment is positively correlated to the maximum medial knee contact force
6,7
because
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the external knee adduction moment acts as compressive force on the medial
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compartment of the knee joint. Indeed, the maximum value of external knee
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adduction moment during gait was found to be higher in OA patients8, and external knee adduction moment can be regarded as a risk factor for OA
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progression 9. In contrast, Walter et al. reported that a decreasein the
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maximum external knee adduction moment did not always guarantee adecrease ofthe maximum medial knee contact force 3. This is because an
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increase in external knee flexion or extension moment leads to anincrease inquadriceps or hamstring tension and, consequently,to anincrease in the medial knee contact force even if the external knee adduction moment decreases. It is unknown whether the maximum external adduction moment could be a real measure to predict the maximum medial knee contact force. Musculo-skeletal model-based computational analysis works as a powerful tool to investigate the medial knee contact force because it can be applied for calculating joint contact forces in noninvasive manner by kinematic and kinetic data. With the use of musculoskeletal model–based simulation
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analysis, some studies have shown that there is a correlation between the external knee adduction moment and the medial knee contact force
10,11.In
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these studies, inverse dynamic analysis was performed to calculate the
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medial knee contact force using knee joint model with muscles and ligaments.
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These studies analyzed the gait data of young subjects, butno study involved olderpeople.
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Gait pattern with ageing are individual and could be characterized by short
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stride, wide base, slow speed, flexed knee and limited ankle dorsiflexion angle, all of which areusually depended on decreased physical functions or
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malalignment12. Because of such large individual differences, a large numberof gait data must be analyzed to investigate the relationship between the external knee adduction moment and the medial knee contact force in older people.Thus, the aim of this study was to investigate the correlation between the external knee adduction moment and the medial knee contact force during gait for a large number of older people using musculo-skeletal model-based simulation analysis.
Methods
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Measurement protocols Community-dwelling 122 olderpeople(31 male and 91 female) participated
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in this study. The subjects were 73.8 ± 6.3 years old, 153.9 ± 7.5 cm in height,
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and 51.1 ± 7.4 kg in weight. They had 1) no cognitive impairment insufficient
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to understand instructions, 2) no serious neuro-muscular impairment insufficiently to prevent measurements, and 3) no difficultyin ambulating
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independently and thus no need for daily life assistance. Written informed
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consent was obtained from each subject. The study was approved by the Ethical Review Board of Osaka Prefecture University.
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Three-dimensional motion analyses and lower extremity muscle activity measurements were performed during standing and gait conditions. In the assessment for the standing condition, the subjects were instructed to stand on a force plate in a relaxed posture with both legs slightly apart, and this posture was captured for 1 s. For gait assessment, the subjects were instructed to walk as usual at their normal speedswhile passing over the force plate. The trials in which the subjects failed to record a complete step on the force plate were rejected.
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Kinetic and kinematic data Three-dimensional coordinates of reflective markers and ground reaction
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force were measured in standing and in gait usinga VICON MX motion
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analysis system (Vicon, Oxford, UK), which is a three dimensional motion
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capture system. This system consists of six infrared cameras with a sampling rate of 100 Hz and two force plates (Kistler, Switzerland) with a sampling
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rate of 1000 Hz. Seventeen markers were attached to each subjectskin at
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anatomical landmarks: anterior superior iliac spines, sacrum, greater
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second metatarsal heads.
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trochanters, medial and lateral knees, medial and lateral ankles, heels and
Markers were processed using Vicon Nexus(Vicon, Oxford, UK).Low-pass Butterworthfilters were applied to the data of reflective marker coordinates and ground reaction force with cutoff frequencies of 5 and 15Hz, respectively.The center of the ankle joint was set as the midpoint between the lateral and medial malleolus markers, and the center of knee joint was defined as the midpoint between the medial and lateral knee markers. The center of the hip joint was calculated from the pelvis markers 13. Joint angles were calculated from the positions of the adjacent joints’ centersfollowingthe
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International Society of Biomechanics’ recommendationsfor definitions joint coordinate systems14.The repeatability of knee joint angle was examined in
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the preliminary test.Trials assessing seven subjects were carried out in
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separate two daysby the same investigator. Intraclass correlation coefficient
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of knee flexion angle at initial contactbetween days was 0.94. Each segment length was calculated from the captured data for standing, and the segment
15.
Inverse dynamic analysis was performed to calculate the joint
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report
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mass and moment of inertia values were calculated by referring to aprevious
moments and joint reaction forcesat ankle, knee and hip joint from the data
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of segment motions and ground reaction forcesusing the Newton–Euler equation.The inverse dynamics programs are implemented in C language and run on a personal computer.
Musculo-skeletal model
A previously described musculo-skeletal model, of which the validity has been verified16, was used in this study. This musculo-skeletal model consists of four segments,i.e., pelvis, thigh, shank, and foot.The ankle, knee, and hipjoints havetwo, one, and three degrees of freedom,respectively. The model
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has 42 muscle tendon units, the anatomical position, optimal length, tendon slack length, and pennation angle were decided based on the data from
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Delp17. The segment lengths were used to scale the simulation model to the
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subject which included scaling of the anatomical position, optimal length and
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tendon slack length. The physiological cross-sectional area of each muscle was determined on the basis ofHorsman’solder people’s muscle data 19.
Hill’s model
was used for calculating muscle force considering the effects of velocity and
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20
muscle stress was extracted from the literature
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18.Maximum
length in accordance with a previous study 21.
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The net joint moments were decomposed into individual muscle forces by solving a minimization problem of the cubic sum of muscle activations at each sampling instance in stance phase 22,23. The knee contact force was calculated as a point load acting on the tibial plateau. The moment vector ⃗
( ) generated by the jth muscle was
expressed as follows: ⃗ where ⃗
()= ⃗
( ) and ⃗
( )× ⃗
( ) = 1,2, ⋯ ,
(1)
( )denote the muscle tension force vector and the
moment arm vector corresponding to j th muscle, respectively, and Ndenotes
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the number of muscles crossing the knee joint. There were 13 muscles crossing knee joint in this model; rectus femoris, vastus medialis, vastus vastus
intermedialis,
medial
and
lateral
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lateralis,
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gastrocnemius,semimembranosus, semitendinosus, biceps femoris long and
vector
⃗
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short head, tensor fascielatae, gracilis, and sartorius.Muscle tension force ( ) was decomposed into
( ) (knee contact forces
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resulting from the muscle tension forces); parallel components along the long
and lateral knee contact forces
and
, were calculated as the sum of the
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and the knee contact forces resulting from the
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knee joint reaction force
, which is the sum of medial
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axis of the femur.The net knee contact force
( ).
muscle tension forces
=
+
=
( )+
(2)
That is, the equilibrium of the adduction/abduction moment of the knee joint is written as follows:
−
where
and
=
( )+
(3)
denote the medio-lateral moment arm lengths, i.e., the
distances from the center of the knee joint to the point of contact forces
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acting on the medial and lateral compartments, respectively; the external knee adduction moment in ⃗
( );and
( ) is
is the external and
,
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knee adduction moment. Themedio-lateral moment arm lengths,
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were fixed at 25% of the knee joint diameter, which was shown in a previous
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study 24.
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Data analysis
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Each joint moment was normalized by the height and body weight (BW) of the individual subjects, and the contact force was normalized by the BW.
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Each joint moment or contact force was represented as a time series throughout the stance phase and was discretized into point data of the stance phase (%SP).
From the knee contact force, the first and second peaks of the external knee adduction moment and medial knee contact force were identified. Here, the maximum of knee adduction torque and medial contact force during 0–50 %SP were defined as the first peaks, and the maximum during 51–100 %SP weredefined as the second peaks. Pearson’s correlation was used to examine the relationship between the
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medial knee contact force and the external knee joint moments of flexion, extension, and adduction using SPSS Statistics version 19. Statistical
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significance was defined as a p-value < 0.05.
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Results
Gait speed was 1.28 ± 0.17 m/s. Several characteristic values of external
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joint moment and medial knee contact force are listed in Table1.
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Figure 1shows the external knee adduction and extension moments during stance phase. The maximum external knee flexion moment was observed at
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the early stance phase, and the maximum external knee extension moment wasobserved at the late stance phase. The external knee adduction moment had two peaks at the early and late stance phases. Of the 122 subjects, 79 subjects (65%) had a higher external adduction moment at the first peak than that at the second peak.
Figure 2shows the medial knee contact force during stance phase. There were two peaks early and late stance phases. Of the 122 subjects, there are 74subjects (61%) who had a higher medial knee contact force at the secondpeak than that at second peak.
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Table 2 listsPearson’s correlation coefficients between the external knee moments and the medial knee contact forces. The maximum medial knee
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contact force had a significant positive correlationwith the maximum
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external adduction moment (r = 0.59) and the extension moment (r = 0.60).
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There was no significant correlation between the maximum medial knee contact force and the maximum external flexion moment. The first peak
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values of the medial knee contact force had a significantly high positive
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correlation with the first peak value of external adduction moment (r = 0.72) and a significant positive correlation with the maximum external flexion
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moment (r = 0.49). The second peak value of medial knee contact force had a significant positive correlation withthe second peak value of external adduction moment (r = 0.63) and the maximum external extension moment (r = 0.67).
Discussion
This study investigated the correlation between the external knee adduction moment and the medial knee contact force in healthy olderpeople.There were a few studies on the correlation between the external
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adduction moment and the medial contact force, but the numbers of subjects in the previous studies were very small25. This is the first study that
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analyzed gait data and performed inverse simulation of musculo-skeletal
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model-based analysis on the data of more than a hundred olderpeople.
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Previous studies in vivo reported that the medial contact force had two peaks in the early and late stance phases, and the maximum medial contact 3,5,25.
These results are in good agreement with
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force was about 1.5–2.5 BW
model-based analysis.
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our data of the medial knee contact force by the musculo-skeletal
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The first peak value of the medial contact force had a high positive correlation with the external adduction moment and a moderate positive correlation with the maximum external flexion moment. This result implies that the first peak of the medial knee contact force could be predicted on the basis ofthe first peak of the external knee adduction moment in normal gait for older people. However, it should be noted that the musculo-skeletal model-based simulation analysis does not include a factor for the co-contraction of knee extension and flexion muscles. The co-contraction induces additional medial knee contact force. Because early stance was the
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most prominent phase of a high level of quadriceps and hamstring co-contraction during stance phase
26,
the co-contraction in theearly stance
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phase would likely have an effect on the medial knee contact force. Therefore,
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it might be necessary to consider the effect of quadriceps and hamstring
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co-contraction for predicting first peak of the medial knee contact force. The second peak value of the medial knee contact force had significant
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moderate positive correlations with both the second peak values of the
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external knee adduction moment and the maximum external extension moment. These results imply that the prediction of the second peak of the
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medial knee contact force from the second peak of the external knee adduction moment would be inadequate, unlike in the case of the relationship between the first peaks of the external knee adduction moment and the medial knee contact force. The sizeable contribution of the gastrocnemius muscle to the medial knee contact force was reported in a previous study 27.The correlation between the second peak of the medial knee contact force and the external extension moment could be ascribed to gastrocnemius muscle tension, which acts in the late stance phase and resists the external extension moment. Both the maximum external knee
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extension moment and the second peak of external adduction moment should be carefully considered when discussing the value of the second peak of the
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medial knee contact force.
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The maximum medial knee contact force was significantly positively
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correlated to the maximum external knee adduction and extension moment. Noyes et al.11 investigated the relationship between the maximum medial
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knee contact force and the maximum external adduction moment for
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patients with ACL deficient by performing musculo-skeletal model-based simulation analysis and reported that both the maximum external adduction
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moment and the maximum external flexion moment showed a statistically significant correlation with the maximum medial knee contact force. Another study that measuredthe medial knee contact force of 1old personin vivo suggested that the external knee flexion moment plays a major role in increasingthe medial knee contact force 3. The results of our study, in which more than a hundred subjects participated, were in good agreement with the results of previous studies that examinedfewer subjects. Most previous studies related to the burden onthe medial knee joint focused only on the maximum external knee adduction moment. We revealed that the maximum
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external knee adduction moment could affect the maximum medial knee contact force to some extent; moreover, both the maximum external knee
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maximum value of knee contact force in older people.
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adduction and the maximum external flexion moment could contribute to the
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There are several limitations of this study.First, oursimulation model did not take the factor of antagonistic muscleco-contraction, such as hamstrings
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activation during early stance, into account.Previous reportshave revealed
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that the results of model-based calculations of the medial knee contact force were in close agreement with the measured data obtained from an 28.
And
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instrumented knee implant for assisting older people with walking
more, in the reportusing an electromyographic based simulation model, antagonist muscle contributes much less to the medial knee contact force in normal walking than agonist muscle or external force27.Even though the medial knee contact force may be low estimated, this study could indicate outline.The second limitation was addressed in the model with a single degree of freedom and single axis for knee joint. We determined muscle contributions to knee flexion/extension moment, which is achieved through tension forces controlled by muscles spanning the knee joint in addition to
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control over the internal/external rotation. Ranges of the moment in internal/external rotation during gait were much smaller than those in
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extension/flexion.; thus, we consideredthat the simplified knee joint model
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with one degree of freedom for flexion/extension could provide adequate
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estimates of for muscle tension force.Anterio-posterior translation of knee flexion/extension axis might be also considered in knee function.
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The external knee adduction moment has been considered a useful measure
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to predict the medial knee contact force,which is a risk factor ofknee OA progression. We analyzed the in-gait medial knee contact force data of more
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than a hundred subjects using the musculo-skeletal model-based analysis, and compared the medial knee contact force to the external knee adduction moment. The maximum medial knee contact force had significant positive correlationswith the maximum external knee adduction moment and the maximum external knee extension moment. These results imply that the maximum value of medial knee contact force was affected by both the maximum external adduction and the extension moment.
Conflict interest No personal relationships exist between any of the authors and other people or organizations that could inappropriately influence this work.
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Acknowledgement
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This research was supported, in part, by the Osaka Gas Group Welfare
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Foundation.
References
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1. Jackson BD, Wluka AE, Teichtahl AJ, Morris ME, Cicuttini FM. Reviewing knee osteoarthritis-a biomechanical perspective. J Sci Med Sport 2004;7:347-357 2. Ledingham J, Regan M, Jones A, Doherty M. Radiographic patterns and associations of
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osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis 1993;52:520-526
3. Walter JP, D'Lima DD, Colwell CW, Jr., Fregly BJ. Decreased knee adduction moment
2010;28:1348-1354
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does not guarantee decreased medial contact force during gait. J Orthop Res
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4. Kutzner I, Kuther S, Heinlein B, Dymke J, Bender A, Halder AM, et al. The effect of valgus braces on medial compartment load of the knee joint - in vivo load measurements in three subjects. J Biomech 2011;44:1354-1360
5. Kinney AL, Besier TF, Silder A, Delp SL, D'Lima DD, Fregly BJ. Changes in in vivo knee contact forces through gait modification. J Orthop Res 2013;31:434-440
6. Astephen JL, Deluzio KJ, Caldwell GE, Dunbar MJ. Biomechanical changes at the hip, knee, and ankle joints during gait are associated with knee osteoarthritis severity. J Orthop Res 2008;26:332-341
7. Hurwitz DE, Ryals AB, Case JP, Block JA, Andriacchi TP. The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. J Orthop Res 2002;20:101-107 8. Linley HS, Sled EA, Culham EG, Deluzio KJ. A biomechanical analysis of trunk and pelvis motion during gait in subjects with knee osteoarthritis compared to control subjects. Clin Biomech 2010;25:1003-1010 9. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at baseline
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can predict radiographic disease progression in medial compartment knee osteoarthritis. Ann Rheum Dis 2002;61:617-622 10. Shelburne KB, Torry MR, Steadman JR, Pandy MG. Effects of foot orthoses and valgus bracing on the knee adduction moment and medial joint load during gait. Clin Biomech 2008;23:814-821
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11. Noyes FR, Schipplein OD, Andriacchi TP, Saddemi SR, Weise M. The anterior cruciate
ligament-deficient knee with varus alignment. An analysis of gait adaptations and dynamic joint loadings. Am J Sports Med 1992;20:707-716
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12. Neumann D. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. St. Louis: Mosby; 2002
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13. Bell AL, Pedersen DR, Brand RA. A comparison of the accuracy of several hip center location prediction methods. J Biomech 1990;23:617-621
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14. Wu G, Siegler S, Allard P, Kirtley C, Leardini A, Rosenbaum D, et al. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion-part I: ankle, hip, and spine. J Biomech
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2002;35:543-548
15. Ae M, Tang H, Yokoi T. Estimation of inertia properties of the body segments in Japanese athletes [in Japanese]. Biomechanism 1992;11:23-33
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16. Ogaya S, Naito H, Okita Y, Iwata A, Higuchi Y, Fuchioka S, et al. Contributions of muscle tension force on medial knee contact force in normal and fast walking.
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Journal of Mechanics in Medicine and Biology 2013;, submitted
17. Delp SL, Loan JP, Hoy MG, Zajac FE, Topp EL, Rosen JM. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE Trans Biomed Eng 1990;37:757-767
18. Klein Horsman MD, Koopman HF, van der Helm FC, Prose LP, Veeger HE. Morphological muscle and joint parameters for musculoskeletal modelling of the lower extremity. Clin Biomech 2007;22:239-247
19. Cleather DJ, Goodwin JE, Bull AM. An optimization approach to inverse dynamics provides insight as to the function of the biarticular muscles during vertical jumping. Ann Biomed Eng 2011;39:147-160
20. Hill AV. The heat of shortening and the dynamic constants of muscle. Proc Roy Soc Lond B Biol Sci 1938;126:136-195 21. Buchanan TS, Lloyd DG, Manal K, Besier TF. Neuromusculoskeletal modeling: estimation of muscle forces and joint moments and movements from measurements of neural command. J Appl Biomech 2004;20:367-395 22. Crowninshield RD, Brand RA. A physiologically based criterion of muscle force
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prediction in locomotion. J Biomech 1981;14:793-801 23. Rasmussen J, Damsgaard M, Voigt M. Muscle recruitment by the min/max criterion -- a comparative numerical study. J Biomech 2001;34:409-415 24. Henriksen M, Simonsen EB, Alkjaer T, Lund H, Graven-Nielsen T, Danneskiold-Samsoe B, et al. Increased joint loads during walking--a consequence of pain relief in knee
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osteoarthritis. Knee 2006;13:445-450
25. Zhao D, Banks SA, Mitchell KH, D'Lima DD, Colwell CW, Jr., Fregly BJ. Correlation between the knee adduction torque and medial contact force for a variety of gait
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patterns. J Orthop Res 2007;25:789-797
26. Schmitt LC, Rudolph KS. Influences on knee movement strategies during walking in
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persons with medial knee osteoarthritis. Arthritis Rheum 2007;57:1018-1026 27. Winby CR, Lloyd DG, Besier TF, Kirk TB. Muscle and external load contribution to knee
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joint contact loads during normal gait. J Biomech 2009;42:2294-2300 28. Kim HJ, Fernandez JW, Akbarshahi M, Walter JP, Fregly BJ, Pandy MG. Evaluation of predicted knee-joint muscle forces during gait using an instrumented knee implant.
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J Orthop Res 2009;27:1326-1331
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Figure 1 External knee joint moments
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External knee joint moments during stance phase (mean ± standard deviation). (A): knee adduction moment, and (B): knee extension moment. Figure 2 Medial knee contact force
Force on medial compartment of tibio-femoral joint (mean ± standard deviation) during stance phase.
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Figure 1
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Figure 2
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Table 1 External knee moment and medial knee contact force.
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Mean ± Standard Measure
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deviation
Adduction (first peak) Adduction (second peak)
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External knee moment (Nm/%BW*height)
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Maximum flexion
2.58 ± 1.41 2.22 ± 1.35 2.80 ± 1.62 4.63 ± 2.24
Maximum
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Maximum extension
2.62 ± 0.86
First peak
2.13 ± 0.67
Second peak
2.39 ± 0.92
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Medial knee contact force (BW)
2.77 ± 1.43
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Maximum adduction
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Table 2 Correlation between external knee moment and medial knee contact force.
Measure
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coefficient
p - value
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Correlation
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Maximum medial knee contact force vs.
< 0.001
0.60**
< 0.001
0.72**
< 0.001
Maximum flexion moment
0.49**
< 0.001
Maximum extension moment
0.07
Maximum flexion moment
0.26
0.122
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Maximum extension moment
0.59**
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Maximum adduction moment
First peak of medial knee contact force vs.
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First peak of adduction moment
0.483
Second peak of medial knee contact force vs. Second peak of adduction moment
0.63**
Maximum flexion moment
0.11
Maximum extension moment
0.67**
< 0.001 0.252 < 0.001
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S0966-6362(14)00496-2 http://dx.doi.org/doi:10.1016/j.gaitpost.2014.04.205 GAIPOS 4201
To appear in:
Gait & Posture
Received date: Revised date: Accepted date:
19-9-2013 11-4-2014 27-4-2014
Please cite this article as: Ogaya Shinya, Naito Hisashi, Iwata Akira, Higuchi Yumi, Fuchioka Satoshi, Tanaka Masao.Knee adduction moment and medial knee contact force during gait in older people.Gait and Posture http://dx.doi.org/10.1016/j.gaitpost.2014.04.205 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Knee adduction moment and medial knee contact forceduring gait inolder people
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Author:Shinya Ogaya1,2),Hisashi Naito2),Akira Iwata1), Yumi Higuchi1),
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Satoshi Fuchioka1), Masao Tanaka2)
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1) Division of Physical Therapy, Department of Comprehensive Rehabilitation, Osaka
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Prefecture University, Osaka, Japan
3-7-30, Habikino,Habikino-shi, Osaka, 583-8555, Japan
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Tel : +81-72-9502111Fax : +81-72-9502130E-mail : [email protected]
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2) Division of Bioengineering, Department of Mechanical Science and Bioengineering,
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Graduate School of Engineering Science, Osaka University 1-3 Machikaneyama, Toyonaka, Osaka, 560-8531,Japan
Highlights
We examine the relationship between medial knee contact force and knee adduction moment during gait in older people
We calculated the medial contact force using musculo-skeletal based-simulation analysis for 122 older people.
The medial knee contact force moderately correlated to the external adduction moment as well as the extension moment.
The medial knee contact force could be predicted by both adduction and extension moment.
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Abstract
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External knee adduction moment has been studied as a surrogate for
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medial knee contact force.However, it is not known whether adduction
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moment is a rational measure for predicting medial knee contact force. The aim of this study was to investigate the correlation between knee adduction
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moment and medial knee contact forceinolderpeople, using musculo-skeletal
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simulation analysis. One hundred and twenty-two healthy oldersubjects participated in this study. Knee moment and medial knee contact force were
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calculated based on inverse dynamics analysis of normal walking. Muscle force and joint reaction force were used to determine the medial knee contact force during stance phase. The results showed that the maximum medial knee contact force was moderately correlated to the maximum knee adduction (r=0.59) as well as the maximum extension moment (r=0.60). The first peak of medial knee contact force had a significant strong correlation with the first peak of adduction moment and a moderate correlation with the maximum flexion moment. The second peak of medial knee contact force had a significant moderate correlation with both the second peak of adduction
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and the maximum extension moment. These results implied that the maximum adduction moment value could be used, to some extent,as a
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measure of the maximum medial knee contact force.
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Keywords:
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adduction moment, medial knee contact force, gait, simulation, older people
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Introduction
Osteoarthritis (OA) is a major joint diseasethat restricts activities of daily
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living. The risk of developing OA increases with age. Adverse mechanical loading of the knee, such as repetitive and high-magnitude joint load, is believed to contribute to the development of knee OA 1. Knee OA is developed predominantly in the medial compartment of the tibiofemoral joint
2.
Measurement of medial knee contact force, i.e.,contact force on the medial compartment of the tibio-femoral joint, would be valuable for identifying the risk of knee OA development. However,thus far, it has been impossible to measure medial knee contact force in a noninvasive manner, andthe number of studies on medial knee contact force measurement is limited 3-5.
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It is considered that the maximum external knee adduction moment is positively correlated to the maximum medial knee contact force
6,7
because
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the external knee adduction moment acts as compressive force on the medial
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compartment of the knee joint. Indeed, the maximum value of external knee
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adduction moment during gait was found to be higher in OA patients8, and external knee adduction moment can be regarded as a risk factor for OA
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progression 9. In contrast, Walter et al. reported that a decreasein the
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maximum external knee adduction moment did not always guarantee adecrease ofthe maximum medial knee contact force 3. This is because an
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increase in external knee flexion or extension moment leads to anincrease inquadriceps or hamstring tension and, consequently,to anincrease in the medial knee contact force even if the external knee adduction moment decreases. It is unknown whether the maximum external adduction moment could be a real measure to predict the maximum medial knee contact force. Musculo-skeletal model-based computational analysis works as a powerful tool to investigate the medial knee contact force because it can be applied for calculating joint contact forces in noninvasive manner by kinematic and kinetic data. With the use of musculoskeletal model–based simulation
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analysis, some studies have shown that there is a correlation between the external knee adduction moment and the medial knee contact force
10,11.In
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these studies, inverse dynamic analysis was performed to calculate the
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medial knee contact force using knee joint model with muscles and ligaments.
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These studies analyzed the gait data of young subjects, butno study involved olderpeople.
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Gait pattern with ageing are individual and could be characterized by short
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stride, wide base, slow speed, flexed knee and limited ankle dorsiflexion angle, all of which areusually depended on decreased physical functions or
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malalignment12. Because of such large individual differences, a large numberof gait data must be analyzed to investigate the relationship between the external knee adduction moment and the medial knee contact force in older people.Thus, the aim of this study was to investigate the correlation between the external knee adduction moment and the medial knee contact force during gait for a large number of older people using musculo-skeletal model-based simulation analysis.
Methods
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Measurement protocols Community-dwelling 122 olderpeople(31 male and 91 female) participated
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in this study. The subjects were 73.8 ± 6.3 years old, 153.9 ± 7.5 cm in height,
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and 51.1 ± 7.4 kg in weight. They had 1) no cognitive impairment insufficient
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to understand instructions, 2) no serious neuro-muscular impairment insufficiently to prevent measurements, and 3) no difficultyin ambulating
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independently and thus no need for daily life assistance. Written informed
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consent was obtained from each subject. The study was approved by the Ethical Review Board of Osaka Prefecture University.
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Three-dimensional motion analyses and lower extremity muscle activity measurements were performed during standing and gait conditions. In the assessment for the standing condition, the subjects were instructed to stand on a force plate in a relaxed posture with both legs slightly apart, and this posture was captured for 1 s. For gait assessment, the subjects were instructed to walk as usual at their normal speedswhile passing over the force plate. The trials in which the subjects failed to record a complete step on the force plate were rejected.
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Kinetic and kinematic data Three-dimensional coordinates of reflective markers and ground reaction
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force were measured in standing and in gait usinga VICON MX motion
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analysis system (Vicon, Oxford, UK), which is a three dimensional motion
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capture system. This system consists of six infrared cameras with a sampling rate of 100 Hz and two force plates (Kistler, Switzerland) with a sampling
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rate of 1000 Hz. Seventeen markers were attached to each subjectskin at
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anatomical landmarks: anterior superior iliac spines, sacrum, greater
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second metatarsal heads.
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trochanters, medial and lateral knees, medial and lateral ankles, heels and
Markers were processed using Vicon Nexus(Vicon, Oxford, UK).Low-pass Butterworthfilters were applied to the data of reflective marker coordinates and ground reaction force with cutoff frequencies of 5 and 15Hz, respectively.The center of the ankle joint was set as the midpoint between the lateral and medial malleolus markers, and the center of knee joint was defined as the midpoint between the medial and lateral knee markers. The center of the hip joint was calculated from the pelvis markers 13. Joint angles were calculated from the positions of the adjacent joints’ centersfollowingthe
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International Society of Biomechanics’ recommendationsfor definitions joint coordinate systems14.The repeatability of knee joint angle was examined in
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the preliminary test.Trials assessing seven subjects were carried out in
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separate two daysby the same investigator. Intraclass correlation coefficient
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of knee flexion angle at initial contactbetween days was 0.94. Each segment length was calculated from the captured data for standing, and the segment
15.
Inverse dynamic analysis was performed to calculate the joint
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report
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mass and moment of inertia values were calculated by referring to aprevious
moments and joint reaction forcesat ankle, knee and hip joint from the data
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of segment motions and ground reaction forcesusing the Newton–Euler equation.The inverse dynamics programs are implemented in C language and run on a personal computer.
Musculo-skeletal model
A previously described musculo-skeletal model, of which the validity has been verified16, was used in this study. This musculo-skeletal model consists of four segments,i.e., pelvis, thigh, shank, and foot.The ankle, knee, and hipjoints havetwo, one, and three degrees of freedom,respectively. The model
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has 42 muscle tendon units, the anatomical position, optimal length, tendon slack length, and pennation angle were decided based on the data from
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Delp17. The segment lengths were used to scale the simulation model to the
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subject which included scaling of the anatomical position, optimal length and
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tendon slack length. The physiological cross-sectional area of each muscle was determined on the basis ofHorsman’solder people’s muscle data 19.
Hill’s model
was used for calculating muscle force considering the effects of velocity and
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20
muscle stress was extracted from the literature
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18.Maximum
length in accordance with a previous study 21.
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The net joint moments were decomposed into individual muscle forces by solving a minimization problem of the cubic sum of muscle activations at each sampling instance in stance phase 22,23. The knee contact force was calculated as a point load acting on the tibial plateau. The moment vector ⃗
( ) generated by the jth muscle was
expressed as follows: ⃗ where ⃗
()= ⃗
( ) and ⃗
( )× ⃗
( ) = 1,2, ⋯ ,
(1)
( )denote the muscle tension force vector and the
moment arm vector corresponding to j th muscle, respectively, and Ndenotes
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the number of muscles crossing the knee joint. There were 13 muscles crossing knee joint in this model; rectus femoris, vastus medialis, vastus vastus
intermedialis,
medial
and
lateral
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lateralis,
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gastrocnemius,semimembranosus, semitendinosus, biceps femoris long and
vector
⃗
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short head, tensor fascielatae, gracilis, and sartorius.Muscle tension force ( ) was decomposed into
( ) (knee contact forces
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resulting from the muscle tension forces); parallel components along the long
and lateral knee contact forces
and
, were calculated as the sum of the
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and the knee contact forces resulting from the
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knee joint reaction force
, which is the sum of medial
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axis of the femur.The net knee contact force
( ).
muscle tension forces
=
+
=
( )+
(2)
That is, the equilibrium of the adduction/abduction moment of the knee joint is written as follows:
−
where
and
=
( )+
(3)
denote the medio-lateral moment arm lengths, i.e., the
distances from the center of the knee joint to the point of contact forces
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acting on the medial and lateral compartments, respectively; the external knee adduction moment in ⃗
( );and
( ) is
is the external and
,
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knee adduction moment. Themedio-lateral moment arm lengths,
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were fixed at 25% of the knee joint diameter, which was shown in a previous
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study 24.
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Data analysis
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Each joint moment was normalized by the height and body weight (BW) of the individual subjects, and the contact force was normalized by the BW.
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Each joint moment or contact force was represented as a time series throughout the stance phase and was discretized into point data of the stance phase (%SP).
From the knee contact force, the first and second peaks of the external knee adduction moment and medial knee contact force were identified. Here, the maximum of knee adduction torque and medial contact force during 0–50 %SP were defined as the first peaks, and the maximum during 51–100 %SP weredefined as the second peaks. Pearson’s correlation was used to examine the relationship between the
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medial knee contact force and the external knee joint moments of flexion, extension, and adduction using SPSS Statistics version 19. Statistical
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significance was defined as a p-value < 0.05.
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Results
Gait speed was 1.28 ± 0.17 m/s. Several characteristic values of external
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joint moment and medial knee contact force are listed in Table1.
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Figure 1shows the external knee adduction and extension moments during stance phase. The maximum external knee flexion moment was observed at
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the early stance phase, and the maximum external knee extension moment wasobserved at the late stance phase. The external knee adduction moment had two peaks at the early and late stance phases. Of the 122 subjects, 79 subjects (65%) had a higher external adduction moment at the first peak than that at the second peak.
Figure 2shows the medial knee contact force during stance phase. There were two peaks early and late stance phases. Of the 122 subjects, there are 74subjects (61%) who had a higher medial knee contact force at the secondpeak than that at second peak.
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Table 2 listsPearson’s correlation coefficients between the external knee moments and the medial knee contact forces. The maximum medial knee
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contact force had a significant positive correlationwith the maximum
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external adduction moment (r = 0.59) and the extension moment (r = 0.60).
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There was no significant correlation between the maximum medial knee contact force and the maximum external flexion moment. The first peak
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values of the medial knee contact force had a significantly high positive
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correlation with the first peak value of external adduction moment (r = 0.72) and a significant positive correlation with the maximum external flexion
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moment (r = 0.49). The second peak value of medial knee contact force had a significant positive correlation withthe second peak value of external adduction moment (r = 0.63) and the maximum external extension moment (r = 0.67).
Discussion
This study investigated the correlation between the external knee adduction moment and the medial knee contact force in healthy olderpeople.There were a few studies on the correlation between the external
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adduction moment and the medial contact force, but the numbers of subjects in the previous studies were very small25. This is the first study that
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analyzed gait data and performed inverse simulation of musculo-skeletal
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model-based analysis on the data of more than a hundred olderpeople.
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Previous studies in vivo reported that the medial contact force had two peaks in the early and late stance phases, and the maximum medial contact 3,5,25.
These results are in good agreement with
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force was about 1.5–2.5 BW
model-based analysis.
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our data of the medial knee contact force by the musculo-skeletal
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The first peak value of the medial contact force had a high positive correlation with the external adduction moment and a moderate positive correlation with the maximum external flexion moment. This result implies that the first peak of the medial knee contact force could be predicted on the basis ofthe first peak of the external knee adduction moment in normal gait for older people. However, it should be noted that the musculo-skeletal model-based simulation analysis does not include a factor for the co-contraction of knee extension and flexion muscles. The co-contraction induces additional medial knee contact force. Because early stance was the
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most prominent phase of a high level of quadriceps and hamstring co-contraction during stance phase
26,
the co-contraction in theearly stance
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phase would likely have an effect on the medial knee contact force. Therefore,
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it might be necessary to consider the effect of quadriceps and hamstring
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co-contraction for predicting first peak of the medial knee contact force. The second peak value of the medial knee contact force had significant
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moderate positive correlations with both the second peak values of the
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external knee adduction moment and the maximum external extension moment. These results imply that the prediction of the second peak of the
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medial knee contact force from the second peak of the external knee adduction moment would be inadequate, unlike in the case of the relationship between the first peaks of the external knee adduction moment and the medial knee contact force. The sizeable contribution of the gastrocnemius muscle to the medial knee contact force was reported in a previous study 27.The correlation between the second peak of the medial knee contact force and the external extension moment could be ascribed to gastrocnemius muscle tension, which acts in the late stance phase and resists the external extension moment. Both the maximum external knee
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extension moment and the second peak of external adduction moment should be carefully considered when discussing the value of the second peak of the
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medial knee contact force.
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The maximum medial knee contact force was significantly positively
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correlated to the maximum external knee adduction and extension moment. Noyes et al.11 investigated the relationship between the maximum medial
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knee contact force and the maximum external adduction moment for
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patients with ACL deficient by performing musculo-skeletal model-based simulation analysis and reported that both the maximum external adduction
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moment and the maximum external flexion moment showed a statistically significant correlation with the maximum medial knee contact force. Another study that measuredthe medial knee contact force of 1old personin vivo suggested that the external knee flexion moment plays a major role in increasingthe medial knee contact force 3. The results of our study, in which more than a hundred subjects participated, were in good agreement with the results of previous studies that examinedfewer subjects. Most previous studies related to the burden onthe medial knee joint focused only on the maximum external knee adduction moment. We revealed that the maximum
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external knee adduction moment could affect the maximum medial knee contact force to some extent; moreover, both the maximum external knee
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maximum value of knee contact force in older people.
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adduction and the maximum external flexion moment could contribute to the
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There are several limitations of this study.First, oursimulation model did not take the factor of antagonistic muscleco-contraction, such as hamstrings
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activation during early stance, into account.Previous reportshave revealed
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that the results of model-based calculations of the medial knee contact force were in close agreement with the measured data obtained from an 28.
And
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instrumented knee implant for assisting older people with walking
more, in the reportusing an electromyographic based simulation model, antagonist muscle contributes much less to the medial knee contact force in normal walking than agonist muscle or external force27.Even though the medial knee contact force may be low estimated, this study could indicate outline.The second limitation was addressed in the model with a single degree of freedom and single axis for knee joint. We determined muscle contributions to knee flexion/extension moment, which is achieved through tension forces controlled by muscles spanning the knee joint in addition to
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control over the internal/external rotation. Ranges of the moment in internal/external rotation during gait were much smaller than those in
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extension/flexion.; thus, we consideredthat the simplified knee joint model
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with one degree of freedom for flexion/extension could provide adequate
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estimates of for muscle tension force.Anterio-posterior translation of knee flexion/extension axis might be also considered in knee function.
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The external knee adduction moment has been considered a useful measure
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to predict the medial knee contact force,which is a risk factor ofknee OA progression. We analyzed the in-gait medial knee contact force data of more
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than a hundred subjects using the musculo-skeletal model-based analysis, and compared the medial knee contact force to the external knee adduction moment. The maximum medial knee contact force had significant positive correlationswith the maximum external knee adduction moment and the maximum external knee extension moment. These results imply that the maximum value of medial knee contact force was affected by both the maximum external adduction and the extension moment.
Conflict interest No personal relationships exist between any of the authors and other people or organizations that could inappropriately influence this work.
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Acknowledgement
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This research was supported, in part, by the Osaka Gas Group Welfare
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Foundation.
References
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1. Jackson BD, Wluka AE, Teichtahl AJ, Morris ME, Cicuttini FM. Reviewing knee osteoarthritis-a biomechanical perspective. J Sci Med Sport 2004;7:347-357 2. Ledingham J, Regan M, Jones A, Doherty M. Radiographic patterns and associations of
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osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis 1993;52:520-526
3. Walter JP, D'Lima DD, Colwell CW, Jr., Fregly BJ. Decreased knee adduction moment
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does not guarantee decreased medial contact force during gait. J Orthop Res
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4. Kutzner I, Kuther S, Heinlein B, Dymke J, Bender A, Halder AM, et al. The effect of valgus braces on medial compartment load of the knee joint - in vivo load measurements in three subjects. J Biomech 2011;44:1354-1360
5. Kinney AL, Besier TF, Silder A, Delp SL, D'Lima DD, Fregly BJ. Changes in in vivo knee contact forces through gait modification. J Orthop Res 2013;31:434-440
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11. Noyes FR, Schipplein OD, Andriacchi TP, Saddemi SR, Weise M. The anterior cruciate
ligament-deficient knee with varus alignment. An analysis of gait adaptations and dynamic joint loadings. Am J Sports Med 1992;20:707-716
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12. Neumann D. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. St. Louis: Mosby; 2002
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13. Bell AL, Pedersen DR, Brand RA. A comparison of the accuracy of several hip center location prediction methods. J Biomech 1990;23:617-621
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14. Wu G, Siegler S, Allard P, Kirtley C, Leardini A, Rosenbaum D, et al. ISB recommendation on definitions of joint coordinate system of various joints for the reporting of human joint motion-part I: ankle, hip, and spine. J Biomech
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2002;35:543-548
15. Ae M, Tang H, Yokoi T. Estimation of inertia properties of the body segments in Japanese athletes [in Japanese]. Biomechanism 1992;11:23-33
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16. Ogaya S, Naito H, Okita Y, Iwata A, Higuchi Y, Fuchioka S, et al. Contributions of muscle tension force on medial knee contact force in normal and fast walking.
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Journal of Mechanics in Medicine and Biology 2013;, submitted
17. Delp SL, Loan JP, Hoy MG, Zajac FE, Topp EL, Rosen JM. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE Trans Biomed Eng 1990;37:757-767
18. Klein Horsman MD, Koopman HF, van der Helm FC, Prose LP, Veeger HE. Morphological muscle and joint parameters for musculoskeletal modelling of the lower extremity. Clin Biomech 2007;22:239-247
19. Cleather DJ, Goodwin JE, Bull AM. An optimization approach to inverse dynamics provides insight as to the function of the biarticular muscles during vertical jumping. Ann Biomed Eng 2011;39:147-160
20. Hill AV. The heat of shortening and the dynamic constants of muscle. Proc Roy Soc Lond B Biol Sci 1938;126:136-195 21. Buchanan TS, Lloyd DG, Manal K, Besier TF. Neuromusculoskeletal modeling: estimation of muscle forces and joint moments and movements from measurements of neural command. J Appl Biomech 2004;20:367-395 22. Crowninshield RD, Brand RA. A physiologically based criterion of muscle force
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prediction in locomotion. J Biomech 1981;14:793-801 23. Rasmussen J, Damsgaard M, Voigt M. Muscle recruitment by the min/max criterion -- a comparative numerical study. J Biomech 2001;34:409-415 24. Henriksen M, Simonsen EB, Alkjaer T, Lund H, Graven-Nielsen T, Danneskiold-Samsoe B, et al. Increased joint loads during walking--a consequence of pain relief in knee
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osteoarthritis. Knee 2006;13:445-450
25. Zhao D, Banks SA, Mitchell KH, D'Lima DD, Colwell CW, Jr., Fregly BJ. Correlation between the knee adduction torque and medial contact force for a variety of gait
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26. Schmitt LC, Rudolph KS. Influences on knee movement strategies during walking in
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persons with medial knee osteoarthritis. Arthritis Rheum 2007;57:1018-1026 27. Winby CR, Lloyd DG, Besier TF, Kirk TB. Muscle and external load contribution to knee
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joint contact loads during normal gait. J Biomech 2009;42:2294-2300 28. Kim HJ, Fernandez JW, Akbarshahi M, Walter JP, Fregly BJ, Pandy MG. Evaluation of predicted knee-joint muscle forces during gait using an instrumented knee implant.
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J Orthop Res 2009;27:1326-1331
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Figure 1 External knee joint moments
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External knee joint moments during stance phase (mean ± standard deviation). (A): knee adduction moment, and (B): knee extension moment. Figure 2 Medial knee contact force
Force on medial compartment of tibio-femoral joint (mean ± standard deviation) during stance phase.
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Figure 1
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Figure 2
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Table 1 External knee moment and medial knee contact force.
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Mean ± Standard Measure
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deviation
Adduction (first peak) Adduction (second peak)
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External knee moment (Nm/%BW*height)
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Maximum flexion
2.58 ± 1.41 2.22 ± 1.35 2.80 ± 1.62 4.63 ± 2.24
Maximum
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Maximum extension
2.62 ± 0.86
First peak
2.13 ± 0.67
Second peak
2.39 ± 0.92
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Medial knee contact force (BW)
2.77 ± 1.43
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Maximum adduction
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Table 2 Correlation between external knee moment and medial knee contact force.
Measure
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coefficient
p - value
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Correlation
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Maximum medial knee contact force vs.
< 0.001
0.60**
< 0.001
0.72**
< 0.001
Maximum flexion moment
0.49**
< 0.001
Maximum extension moment
0.07
Maximum flexion moment
0.26
0.122
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Maximum extension moment
0.59**
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Maximum adduction moment
First peak of medial knee contact force vs.
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First peak of adduction moment
0.483
Second peak of medial knee contact force vs. Second peak of adduction moment
0.63**
Maximum flexion moment
0.11
Maximum extension moment
0.67**
< 0.001 0.252 < 0.001
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