- Email: [email protected]
Valgus stress at the knee joint in lumbo-sacral myelomeningocele: A gait analysis evaluation
108
Gait & Posture Monitoring
U. of Western
1995; 3: No 2 Recovery Following a Syndesmosis Sprain of the Ankle S.J. Spaulding Ontario, London,
Maximum vertical GRF and maximum ground reaction forces were monitored
anterior-posterior negative throughout recovery.
and positive
RWJ1t.S Ont.,
N6G IHI
Introduction A syndesmosis sprain results from injury of the syndesmotic ligaments that maintain the relationship between the distal dbia and fibula (Sartoris, 1994). Individuals who sustain injuries to the ankle syndesmosis have longer recovery times than patients with other types of ankIe sprains (Boytim et al, 1991). Pain during the push-off phase of gait and disruption of ankle mortise stability may be major limiting factors in return to activity Taylor et al, 1992). Treatment of syndesmoris sprains is often frustrating because of the long recovery time (Taylor & Bassett, 1993). Rehabilitation includes range of motion and resistance exercises, propricceptio” exercises and lower extremity stretching (Garrick & Requa, 1988). Ankle support may be used to decrease mechanical ankle instability and limit extreme range of motion (Karl&on et J, 1993). Surgical immobilization of the distal tibia and tibula may be required before recovery occurs (cf. Amend&, 1992). The purpose of the present case study was to monitor the recovery of a subject pre- and post-surgical repair of a syndesmosis sprain specifically to evaluate stance phase functioning including push-off and weightbearing through the affected limb. Methodology The subject was a 41 year old female who sustained a syndesmosis sprain following a fall down stairs. GRF were collected pre-surgical ftxatio” of the distal tibia and tibula with a syndesmosis screw. Following eight weeks of “on-weight bearing, the syndesmosis screw was removed and the subject instructed to weightbear as tolerated and to proceed with physiotherapy treatment to increase strength and ROM. A minimum of 5 trials of GRF data during walking in an unbraced condition were collected 4 days post syndesmosis screw removal, then every 3 days for 4 months. Data were also collected at 6 weeks to determine the effects of two ankle orthoses; the Swede-O ankle brace (lace-up boot type) zmd the Sure Step ankle brace pinged stirrup type). These data were compared to non-braced walking trials collected on the same day. Anterior-posterior and vertical ground reaction forces were collected from a” AMTI force plate (Advanced MedicaI Technology, Inc., Boston, U.S.A.), amplified with a data translation amplifier, A/D converted, integrated and stored for analysis.
VALGUS STRESS AT THE KNEE JOINT IN LUMBO-SACRAL MYELOMENINGOCELE : A GAIT ANALYSIS EVALUATION Carolvn Moore BSc, Lucwm Dias MD. Stephen Vankoski MS, Richard Lim MD, John F. Sawark MD Children’s Memorial Hospital, Chicago, Illinois 60614. Introduction Vankoski et al. (1995) have documented typical compensatory kinematic patterns of children with sacrai level myelomeningocele (MM) which include increased pelvic obliquity and rotalo”, increased hip abduction, and increased knee flexion. Patients with MM adopt these patterns m lieu of weak hip musculature and the absence of ankle plrmtaflewors, however. the effect of these compensatory patterns on the knee joint has not been established. A recent study by WiIbams et al. (1993) has show” that 24% of adult, community ambulator patients with spma bifida have symptomatic knee problems mcluding instability and pain. Williams et al. described these patients an walking wth iu~ abductor lurch with the knee in valgus and flexion during stance, followed by a lateral pivot off a fixed pronated foot. Ounpuu et al (1992) concluded that the appearance of a “valgus thrust” at the knee during the loading response results from a combination of excessive protraction of the pelvis, increased knee flexion, and an externally rotated flail foot. They found that 16 of 20 knees had a “et inremal abduction (valgus) moment in stance, although the degree of external tibial torsion measured climcatly was not reported. The purpose of this study war to evaluate the “et internal coronal plane knee moment at knee during stance of children with different degrees of external tibia! torsion. Methodology Thirty three patlents with lumbo-sacrai MM (40 knees) were evaluared m a chmcal gait analysis laboratory to obtam kinematic and lunetx data for the lower extremities. The mean age of the patients was II.5 years (range 5 18 years). All patients ambulated with AFOs, but without external support. Kinematic data was collected using a three dimensional motion measurement system (Oxford Metrics, Oxford, England). m conjunction with the marker set described by Kadaba et al. (1990). Joint angles were calculated for the pelvis, hip, knee and ankle, as described by Kadaba. The kinetic data was collected using two force platforms (AMTI, Newton, MA) and “et internal joint moments were calculated using ~“verse dynamics (Winter, 1990). The clinicai measurement of thigh foot angle (TFA) was used to divide the Patients into two groups. Seventeen patients had a TFA of greater than or equal to +20 degrees (TFAX20) and sixteen patients had a TFA of between +I0 and +20 degrees (TFA
Following syndesmosis bearing, as noted by the vertical phases of gait (anterior-posterior and maximum vertical and a-0 preinjury state. Data coll&d demonstmted 50% of non-braced GRF 150% for the Sure-step. pin removal.
screw removal, increases in maximum weightground reaction forces, and braking and push-off GRF) were evident, however normal FRF curves oush-off values did not auicklv approach the while the subject wore & a&e orthosis maximal push off for tke Swede-O brace and data approach normal at 4 months post-syndesmosis
DiXUS.Si0n Progression of recovery followed the expectations described in the literature; recovery was slow and there was difficulty weight-bearing and during the push-off phase of stance. The extensive length of time required for recovery following surgery were probably the result of decreased range of motion, decreased strength due to a” extensive length of time non-weight bearing, and pain during weightbearing and plantar-tlexion against resistance. Ankle orthoses dramatically changed the GRF in this subject, however changes varied depending on the type of orthosis. The orthosis which controlled plantar-dorsiflexion actually produced a decrease in the force output, possible Full ankle range because it altered plantar ilexian required to push-off effectively. of motion in the sagitti plane with a restriction of inversion and eversion with rigid support around the disti tibio-tibulx joint appeared to encourage force production. References Amend&, A., Foot Ankle, 13: 44-50, 1992. Boytim, M., et al,. America” Journal of Sports Medicine, 19: 294-298. 1991, Ganick, I. & Rqua, R., Clinical Sports Medicine, 7:29-36, 1988. 1990. Greene. T.. & Hillman. S.. A. Journal of Soorts Medicine. 18, 5: 498-506, Karl&, 1: & Lansing&, O., Clinical Orthipaedics, 253-261, 1992. Karlsso”, J., et al., Sports Medicine, 16: 210-215, 1993. Sartoris, D., The Journal of Foot and Ankle Surgery, 33: 102-107, 1994. Taylor, D., et al., America” Journal of Sparts Medicine, 20: 146-150, 1992. Taylor, D. & Bassett, F. The Physician and Sports Medicine, 21, 12: 39-46, 1993. The author acknowledges and Ottawa, Ontario.
support from Sports Medicine
World,
London,
Ontario
ANOVA The tare moments were compared at the dlstmct ga” cycle events of opposrte foot off (OFO) and opposite foot contact (OFC) RWlltS All seventeen patxnts in the TFA 220 group (20 knees) had a “et mternal varos moment at the knee throughout the stance phase. Eleven of sixteen panems in the TFAO.O5). The foot progression angle was significantly external at OF0 and OFC for the TFAt20 group when compared to TFAc20 group (~‘0.05). Discussion Both groups had the increased dgnatmc range of pelwc rotation and the decreased hip abductor moment. The decreased hio abductor moment results from a shift of the trunk towards the stance side which decreases the demand on the weak hip abductors. Conversely. this movement increases the stress on the medial aspect of the flexed knee, as the ground reaction force moves laterally from the kneeJoint center. Although there was no Tignihcant difference in the dynarmc range of pelvic rotation and the magnitude of lxp abduction moment between the TFAx20 group and the TFA<20 group, the TFA>20 group had greater pelvic excursmn. a greater decrease in the hip abductor moment throughour rhe stance phase and greater stance phase knee flexion The greater varus stress on the knee in the TFA>ZO group may be attributed 10 a combination of the shghtly increased compensatory motions of the pelwsitrunk and sigmficant external fool progresslo” angle wluch results from excessive tibml torsion. Our results indicate that this rotational deformity of the tibia, in association with increased pelvic rotation and lateral :ru”k sway, accounts for the abnormal internal varus moment at the knee. This abnormal stress on the knee may explain the high incidence of knee pain in the adult spina bifida population. Further evaluation of the stress on the knee jmnts of cbddren wth MM is warranted and ~111 assist in direcung treatment wlwh may avoid knee pain commonly experienced as adults. Acknowledgments The authors would hke to thank Claudia Kelp-Lenane for performing the physical rherapy evaluations a”d Anton Weyers for his assistance 1” collecting and processing the gait data.
mternal
References Vankoskl, S er al. Gail and Posrurr. in press. 1995. Ounpuu. S et al. Procerrlinnm ofNACOB II. 1992. Wlllinms.
J el al.
Jormal
of Pediarrrc
Orthopmdics.
Kadaba. M et al Journal of Pedintrrr Orihopoedm. Wmter. D Emmechanics of HumanMovement
2nd
1993 1990 ed 1990
Gait & Posture Monitoring
U. of Western
1995; 3: No 2 Recovery Following a Syndesmosis Sprain of the Ankle S.J. Spaulding Ontario, London,
Maximum vertical GRF and maximum ground reaction forces were monitored
anterior-posterior negative throughout recovery.
and positive
RWJ1t.S Ont.,
N6G IHI
Introduction A syndesmosis sprain results from injury of the syndesmotic ligaments that maintain the relationship between the distal dbia and fibula (Sartoris, 1994). Individuals who sustain injuries to the ankle syndesmosis have longer recovery times than patients with other types of ankIe sprains (Boytim et al, 1991). Pain during the push-off phase of gait and disruption of ankle mortise stability may be major limiting factors in return to activity Taylor et al, 1992). Treatment of syndesmoris sprains is often frustrating because of the long recovery time (Taylor & Bassett, 1993). Rehabilitation includes range of motion and resistance exercises, propricceptio” exercises and lower extremity stretching (Garrick & Requa, 1988). Ankle support may be used to decrease mechanical ankle instability and limit extreme range of motion (Karl&on et J, 1993). Surgical immobilization of the distal tibia and tibula may be required before recovery occurs (cf. Amend&, 1992). The purpose of the present case study was to monitor the recovery of a subject pre- and post-surgical repair of a syndesmosis sprain specifically to evaluate stance phase functioning including push-off and weightbearing through the affected limb. Methodology The subject was a 41 year old female who sustained a syndesmosis sprain following a fall down stairs. GRF were collected pre-surgical ftxatio” of the distal tibia and tibula with a syndesmosis screw. Following eight weeks of “on-weight bearing, the syndesmosis screw was removed and the subject instructed to weightbear as tolerated and to proceed with physiotherapy treatment to increase strength and ROM. A minimum of 5 trials of GRF data during walking in an unbraced condition were collected 4 days post syndesmosis screw removal, then every 3 days for 4 months. Data were also collected at 6 weeks to determine the effects of two ankle orthoses; the Swede-O ankle brace (lace-up boot type) zmd the Sure Step ankle brace pinged stirrup type). These data were compared to non-braced walking trials collected on the same day. Anterior-posterior and vertical ground reaction forces were collected from a” AMTI force plate (Advanced MedicaI Technology, Inc., Boston, U.S.A.), amplified with a data translation amplifier, A/D converted, integrated and stored for analysis.
VALGUS STRESS AT THE KNEE JOINT IN LUMBO-SACRAL MYELOMENINGOCELE : A GAIT ANALYSIS EVALUATION Carolvn Moore BSc, Lucwm Dias MD. Stephen Vankoski MS, Richard Lim MD, John F. Sawark MD Children’s Memorial Hospital, Chicago, Illinois 60614. Introduction Vankoski et al. (1995) have documented typical compensatory kinematic patterns of children with sacrai level myelomeningocele (MM) which include increased pelvic obliquity and rotalo”, increased hip abduction, and increased knee flexion. Patients with MM adopt these patterns m lieu of weak hip musculature and the absence of ankle plrmtaflewors, however. the effect of these compensatory patterns on the knee joint has not been established. A recent study by WiIbams et al. (1993) has show” that 24% of adult, community ambulator patients with spma bifida have symptomatic knee problems mcluding instability and pain. Williams et al. described these patients an walking wth iu~ abductor lurch with the knee in valgus and flexion during stance, followed by a lateral pivot off a fixed pronated foot. Ounpuu et al (1992) concluded that the appearance of a “valgus thrust” at the knee during the loading response results from a combination of excessive protraction of the pelvis, increased knee flexion, and an externally rotated flail foot. They found that 16 of 20 knees had a “et inremal abduction (valgus) moment in stance, although the degree of external tibial torsion measured climcatly was not reported. The purpose of this study war to evaluate the “et internal coronal plane knee moment at knee during stance of children with different degrees of external tibia! torsion. Methodology Thirty three patlents with lumbo-sacrai MM (40 knees) were evaluared m a chmcal gait analysis laboratory to obtam kinematic and lunetx data for the lower extremities. The mean age of the patients was II.5 years (range 5 18 years). All patients ambulated with AFOs, but without external support. Kinematic data was collected using a three dimensional motion measurement system (Oxford Metrics, Oxford, England). m conjunction with the marker set described by Kadaba et al. (1990). Joint angles were calculated for the pelvis, hip, knee and ankle, as described by Kadaba. The kinetic data was collected using two force platforms (AMTI, Newton, MA) and “et internal joint moments were calculated using ~“verse dynamics (Winter, 1990). The clinicai measurement of thigh foot angle (TFA) was used to divide the Patients into two groups. Seventeen patients had a TFA of greater than or equal to +20 degrees (TFAX20) and sixteen patients had a TFA of between +I0 and +20 degrees (TFA
Following syndesmosis bearing, as noted by the vertical phases of gait (anterior-posterior and maximum vertical and a-0 preinjury state. Data coll&d demonstmted 50% of non-braced GRF 150% for the Sure-step. pin removal.
screw removal, increases in maximum weightground reaction forces, and braking and push-off GRF) were evident, however normal FRF curves oush-off values did not auicklv approach the while the subject wore & a&e orthosis maximal push off for tke Swede-O brace and data approach normal at 4 months post-syndesmosis
DiXUS.Si0n Progression of recovery followed the expectations described in the literature; recovery was slow and there was difficulty weight-bearing and during the push-off phase of stance. The extensive length of time required for recovery following surgery were probably the result of decreased range of motion, decreased strength due to a” extensive length of time non-weight bearing, and pain during weightbearing and plantar-tlexion against resistance. Ankle orthoses dramatically changed the GRF in this subject, however changes varied depending on the type of orthosis. The orthosis which controlled plantar-dorsiflexion actually produced a decrease in the force output, possible Full ankle range because it altered plantar ilexian required to push-off effectively. of motion in the sagitti plane with a restriction of inversion and eversion with rigid support around the disti tibio-tibulx joint appeared to encourage force production. References Amend&, A., Foot Ankle, 13: 44-50, 1992. Boytim, M., et al,. America” Journal of Sports Medicine, 19: 294-298. 1991, Ganick, I. & Rqua, R., Clinical Sports Medicine, 7:29-36, 1988. 1990. Greene. T.. & Hillman. S.. A. Journal of Soorts Medicine. 18, 5: 498-506, Karl&, 1: & Lansing&, O., Clinical Orthipaedics, 253-261, 1992. Karlsso”, J., et al., Sports Medicine, 16: 210-215, 1993. Sartoris, D., The Journal of Foot and Ankle Surgery, 33: 102-107, 1994. Taylor, D., et al., America” Journal of Sparts Medicine, 20: 146-150, 1992. Taylor, D. & Bassett, F. The Physician and Sports Medicine, 21, 12: 39-46, 1993. The author acknowledges and Ottawa, Ontario.
support from Sports Medicine
World,
London,
Ontario
ANOVA The tare moments were compared at the dlstmct ga” cycle events of opposrte foot off (OFO) and opposite foot contact (OFC) RWlltS All seventeen patxnts in the TFA 220 group (20 knees) had a “et mternal varos moment at the knee throughout the stance phase. Eleven of sixteen panems in the TFAO.O5). The foot progression angle was significantly external at OF0 and OFC for the TFAt20 group when compared to TFAc20 group (~‘0.05). Discussion Both groups had the increased dgnatmc range of pelwc rotation and the decreased hip abductor moment. The decreased hio abductor moment results from a shift of the trunk towards the stance side which decreases the demand on the weak hip abductors. Conversely. this movement increases the stress on the medial aspect of the flexed knee, as the ground reaction force moves laterally from the kneeJoint center. Although there was no Tignihcant difference in the dynarmc range of pelvic rotation and the magnitude of lxp abduction moment between the TFAx20 group and the TFA<20 group, the TFA>20 group had greater pelvic excursmn. a greater decrease in the hip abductor moment throughour rhe stance phase and greater stance phase knee flexion The greater varus stress on the knee in the TFA>ZO group may be attributed 10 a combination of the shghtly increased compensatory motions of the pelwsitrunk and sigmficant external fool progresslo” angle wluch results from excessive tibml torsion. Our results indicate that this rotational deformity of the tibia, in association with increased pelvic rotation and lateral :ru”k sway, accounts for the abnormal internal varus moment at the knee. This abnormal stress on the knee may explain the high incidence of knee pain in the adult spina bifida population. Further evaluation of the stress on the knee jmnts of cbddren wth MM is warranted and ~111 assist in direcung treatment wlwh may avoid knee pain commonly experienced as adults. Acknowledgments The authors would hke to thank Claudia Kelp-Lenane for performing the physical rherapy evaluations a”d Anton Weyers for his assistance 1” collecting and processing the gait data.
mternal
References Vankoskl, S er al. Gail and Posrurr. in press. 1995. Ounpuu. S et al. Procerrlinnm ofNACOB II. 1992. Wlllinms.
J el al.
Jormal
of Pediarrrc
Orthopmdics.
Kadaba. M et al Journal of Pedintrrr Orihopoedm. Wmter. D Emmechanics of HumanMovement
2nd
1993 1990 ed 1990