Flexed Knee Posture Research Articles

Subchondral and Trabecular Bone Respond Differently to Exercise in Juvenile Sheep

Evaluating the responses of subchondral and underlying trabecular bone properties to exercise interventions have implications for understanding normal developmental processes as well as the etiology of diseases affecting these tissues. We hypothesized that exercise would result in (1) increased subchondral and trabecular thickness and density, and increased bone volume fraction, (2) the distribution of increased bone properties would reflect experimentally induced postural differences, and (3) shallower trabecular bone would show a greater response to exercise than deeper trabecular bone. To evaluate these hypotheses we randomly assigned thirty juvenile sheep to flat exercise (n=11), inclined exercise (15% grade; n=11) which used more flexed knee postures, and non‐exercised control (n=8) groups. Exercise was conducted on motorized treadmills twice daily for 20 min at 1.12m/s for 60 days. Distal femora were micro‐CT‐scanned at 50μm resolution. Trabecular thickness, apparent density, bone volume fraction, anisotropy, as well as subchondral thickness and apparent density were measured using custom algorithms in AMIRA, ImageJ and MATLAB. Subchondral thickness showed significant and predictable response to exercise and with approximately 20% thicker bone in both exercise groups compared to controls, and postural changes with increased thickness toward the posterior side of the condyle in the incline group. Subchondral density did not increase substantially with exercise. In contrast trabecular density was increased slightly with exercise (~5%) but the response did not correspond to incline‐exercised and control groups. These results suggest a greater responsiveness to exercise in subchondral than trabecular bone, and imply that increases in stiffness in these tissues may be achieved through modulation of different tissue properties.Support or Funding InformationNational Science Foundation 1638756

Trabecular Bone Structure in the Distal Femur of Humans, Apes, and Baboons.

Trabecular bone structure has been used to investigate the relationship between skeletal form and locomotor behavior on the premise that trabecular bone remodels in response to loading during an animal's lifetime. The aim of this study is to characterize human distal femoral trabecular bone structure in comparison to three non-human primate taxa and relate the patterns of trabecular structural variation in the distal femur to knee posture during habitual locomotor behavior. A whole-epiphysis approach was applied using microCT scans of the distal femora of extant Homo sapiens, Pan troglodytes, Pongo pygmaeus, and Papio spp. (N = 48). Bone volume fraction (BV/TV) was quantified in the epiphysis and analyzed with both whole-condyle and a novel sector analysis. The results indicate high trabecular bone structural variation within and between species. The sector analysis reveals the most distinctive patterns in the stereotypically loaded human knee, with a pattern of high BV/TV distally. In general, Pan, Pongo, and Papio show evidence of flexed knee postures, typical of their locomotor behaviors, with regions of high BV/TV posteriorly within the condyles. The pairwise comparisons confirm the unique pattern in Homo and reveal a shared high BV/TV region in the patellar groove of both Homo and Papio. The distinct pattern found in Homo relative to the other primate taxa suggests a plastic response to unique loading patterns during bipedal locomotion. Results may facilitate resolving the antiquity of habitual bipedality in the hominin fossil record. This analysis also presents new approaches for statistical analysis of whole-epiphysis trabecular bone structure. Anat Rec, 2018. © 2018 American Association for Anatomy.

Trabecular bone patterning in the hominoid distal femur.

BackgroundIn addition to external bone shape and cortical bone thickness and distribution, the distribution and orientation of internal trabecular bone across individuals and species has yielded important functional information on how bone adapts in response to load. In particular, trabecular bone analysis has played a key role in studies of human and nonhuman primate locomotion and has shown that species with different locomotor repertoires display distinct trabecular architecture in various regions of the skeleton. In this study, we analyse trabecular structure throughout the distal femur of extant hominoids and test for differences due to locomotor loading regime.MethodsMicro-computed tomography scans of Homo sapiens (n = 11), Pan troglodytes (n = 18), Gorilla gorilla (n = 14) and Pongo sp. (n = 7) were used to investigate trabecular structure throughout the distal epiphysis of the femur. We predicted that bone volume fraction (BV/TV) in the medial and lateral condyles in Homo would be distally concentrated and more anisotropic due to a habitual extended knee posture at the point of peak ground reaction force during bipedal locomotion, whereas great apes would show more posteriorly concentrated BV/TV and greater isotropy due to a flexed knee posture and more variable hindlimb use during locomotion.ResultsResults indicate some significant differences between taxa, with the most prominent being higher BV/TV in the posterosuperior region of the condyles in Pan and higher BV/TV and anisotropy in the posteroinferior region in Homo. Furthermore, trabecular number, spacing and thickness differ significantly, mainly separating Gorilla from the other apes.DiscussionThe trabecular architecture of the distal femur holds a functional signal linked to habitual behaviour; however, there was more similarity across taxa and greater intraspecific variability than expected. Specifically, there was a large degree of overlap in trabecular structure across the sample, and Homo was not as distinct as predicted. Nonetheless, this study offers a comparative sample of trabecular structure in the hominoid distal femur and can contribute to future studies of locomotion in extinct taxa.

How does patellar tendon advancement alter the knee extensor mechanism in children treated for crouch gait?

BackgroundThe patellar tendon advancement (PTA) procedure, often coupled with a distal femoral extension osteotomy (DFEO), is increasingly used to treat persistent crouch gait. In this study, we investigated relationships between patella position, knee flexion, and the patellar tendon moment arm in children treated with the DFEO and PTA procedures. MethodsWe retrospectively analyzed pre- and post-operative radiographs and gait metrics from 63 knees that underwent DFEO and PTA procedures at Gillette Children’s Specialty Healthcare. A computational musculoskeletal model of the knee was used to simulate the PTA procedure and predict the effects on the patellar tendon moment arm. ResultsApproximately 80% of the knees exhibited patella alta prior to surgery. Post-operatively, 86% of the knees exhibited patella baja. The surgically altered patella position produced a 13% increase in the patellar tendon moment arm in extended knee postures, which agreed well with model predictions. However, the computational model also suggests that baja may compromise patellar tendon moment arms in flexed knee postures. Crouch gait was significantly reduced postoperatively, with a 27 ± 18° reduction in average knee flexion in stance. There was considerable inter-subject variability in outcomes with nine knees not exhibiting a meaningful enhancement of knee extension (<15° change). The subjects who improved were significantly younger and exhibited greater enhancement of the patellar tendon moment arm after surgery. ConclusionsThis study shows that the PTA procedure enhances the lever arm of the knee extensor mechanism, and this factor may be important in resolving crouch gait.

The coupled effects of crouch gait and patella alta on tibiofemoral and patellofemoral cartilage loading in children

BackgroundElevated tibiofemoral and patellofemoral loading in children who exhibit crouch gait may contribute to skeletal deformities, pain, and cessation of walking ability. Surgical procedures used to treat crouch frequently correct knee extensor insufficiency by advancing the patella. However, there is little quantitative understanding of how the magnitudes of crouch and patellofemoral correction affect cartilage loading in gait. MethodsWe used a computational musculoskeletal model to simulate the gait of twenty typically developing children and fifteen cerebral palsy patients who exhibited mild, moderate, and severe crouch. For each walking posture, we assessed the influence of patella alta and baja on tibiofemoral and patellofemoral cartilage contact. ResultsTibiofemoral and patellofemoral contact pressures during the stance phase of normal gait averaged 2.2 and 1.0 MPa. Crouch gait increased pressure in both the tibofemoral (2.6–4.3 MPa) and patellofemoral (1.8–3.3 MPa) joints, while also shifting tibiofemoral contact to the posterior tibial plateau. For extended-knee postures, normal patellar positions (Insall-Salvatti ratio 0.8–1.2) concentrated contact on the middle third of the patellar cartilage. However, in flexed knee postures, both normal and baja patellar positions shifted pressure toward the superior edge of the patella. Moving the patella into alta restored pressure to the middle region of the patellar cartilage as crouch increased. ConclusionsThis work illustrates the potential to dramatically reduce tibiofemoral and patellofemoral cartilage loading by surgically correcting crouch gait, and highlights the interaction between patella position and knee posture in modulating the location of patellar contact during functional activities.

Low-Cost Methodology for Skin Strain Measurement of a Flexed Biological Limb.

The purpose of this manuscript is to compute skin strain data from a flexed biological limb, using portable, inexpensive, and easily available resources. We apply and evaluate this approach on a person with bilateral transtibial amputations, imaging left and right residual limbs in extended and flexed knee postures. We map 3-D deformations to a flexed biological limb using freeware and a simple point-and-shoot camera. Mean principal strain, maximum shear strain, as well as lines of maximum, minimum, and nonextension are computed from 3-D digital models to inform directional mappings of the strain field for an unloaded residual limb. Peak tensile strains are ∼0.3 on the anterior surface of the knee in the proximal region of the patella, whereas peak compressive strains are ∼ -0.5 on the posterior surface of the knee. Peak maximum shear strains are ∼0.3 on the posterior surface of the knee. The accuracy and precision of this methodology are assessed for a ground-truth model. The mean point location distance is found to be 0.08 cm, and the overall standard deviation for point location difference vectors is 0.05 cm. This low-cost and mobile methodology may prove critical for applications such as the prosthetic socket interface where whole-limb skin strain data are required from patients in the field outside of traditional, large-scale clinical centers. Such data may inform the design of wearable technologies that directly interface with human skin.

Non-uniform displacements within the Achilles tendon observed during passive and eccentric loading

The goal of this study was to investigate Achilles tendon tissue displacement patterns under passive and eccentric loading conditions. Nine healthy young adults were positioned prone on an examination table with their foot secured to a rotating footplate aligned with the ankle. Subjects cyclically rotated their ankle over a 25° range of motion at 0.5Hz. An inertial load geared to the footplate induced eccentric plantarflexor contractions with dorsiflexion. Passive cyclic ankle motion was also performed over the same angular range of motion. An ultrasound transducer positioned over the distal Achilles tendon was used to collect radiofrequency (RF) images at 70frames/s. Two-dimensional ultrasound elastographic analysis of the RF data was used to track tendon tissue displacements throughout the cyclic motion. Non-uniform tissue displacement patterns were observed in all trials, with the deeper portions of the Achilles tendon consistently exhibiting larger displacements than the superficial tendon (average of 0.9–2.6mm larger). Relative to the passive condition, eccentric loading consistently induced smaller tissue displacements in all tendon regions, except for the superficial tendon in a flexed knee posture. Significantly greater overall tissue displacement was observed in a more extended knee posture (30°) relative to a flexed knee posture (90°). These spatial- and posture-dependent displacement patterns suggest that the tendon undergoes non-uniform deformation under in vivo loading conditions. Such behavior could reflect relative sliding between the distinct tendon fascicles that arise from the gastrocnemius and soleus muscles.

Muscle activity, cross-sectional area, and density following passive standing and whole body vibration: A case series

ObjectiveTo investigate the effects of intermittent passive standing (PS) and whole body vibration (WBV) on the electromyography (EMG) activity, cross-sectional area, and density of lower extremity muscles in individuals with chronic motor complete spinal cord injury (SCI).DesignCase series.MethodsSeven adult men with chronic (≥2 years), thoracic motor complete (AIS A–B) SCI completed a 40-week course of thrice-weekly intermittent PS-WBV therapy, in a flexed knee posture (160°), for 45 minutes per session at a frequency of 45 Hz and 0.6–0.7 mm displacement using the WAVE® Pro Plate, with an integrated EasyStand™ standing frame. EMG was measured in major lower extremity muscles to represent muscle activity during PS-WBV. The cross-sectional area and density of the calf muscles were measured using peripheral quantitative computed tomography at the widest calf cross-section (66% of the tibia length) at pre- and post-intervention. All measured variables were compared between the pre- and post-intervention measurements to assess change after the PS-WBV intervention.ResultsPS-WBV acutely induced EMG activity in lower extremity muscles of SCI subjects. No significant changes in lower extremity EMG activity, muscle cross-sectional area, or density were observed following the 40-week intervention.ConclusionsAlthough acute exposure to PS-WBV can induce electrophysiological activity of lower extremity muscles during PS in men with motor complete SCI, the PS-WBV intervention for 40 weeks was not sufficient to result in enhanced muscle activity, or to increase calf muscle cross-sectional area or density.

Length and activation dependent variations in muscle shear wave speed

Muscle stiffness is known to vary as a result of a variety of disease states, yet current clinical methods for quantifying muscle stiffness have limitations including cost and availability. We investigated the capability of shear wave elastography (SWE) to measure variations in gastrocnemius shear wave speed induced via active contraction and passive stretch. Ten healthy young adults were tested. Shear wave speeds were measured using a SWE transducer positioned over the medial gastrocnemius at ankle angles ranging from maximum dorsiflexion to maximum plantarflexion. Shear wave speeds were also measured during voluntary plantarflexor contractions at a fixed ankle angle. Average shear wave speed increased significantly from 2.6 to 5.6 m s–1 with passive dorsiflexion and the knee in an extended posture, but did not vary with dorsiflexion when the gastrocnemius was shortened in a flexed knee posture. During active contractions, shear wave speed monotonically varied with the net ankle moment generated, reaching 8.3 m s–1 in the maximally contracted condition. There was a linear correlation between shear wave speed and net ankle moment in both the active and passive conditions; however, the slope of this linear relationship was significantly steeper for the data collected during passive loading conditions. The results show that SWE is a promising approach for quantitatively assessing changes in mechanical muscle loading. However, the differential effect of active and passive loading on shear wave speed makes it important to carefully consider the relevant loading conditions in which to use SWE to characterize in vivo muscle properties.

Subchondral Bone Apparent Density and Locomotor Behavior in Extant Primates and Subfossil Lemurs Hadropithecus and Pachylemur

We analyze patterns of subchondral bone apparent density in the distal femur of extant primates to reconstruct differences in knee posture, discriminate among extant species with different locomotor preferences, and investigate the knee postures used by subfossil lemur species Hadropithecus stenognathus and Pachylemur insignis. We obtained computed tomographic scans for 164 femora belonging to 39 primate species. We grouped species by locomotor preference into knuckle-walking, arboreal quadruped, terrestrial quadruped, quadrupedal leaper, suspensory and vertical clinging, and leaping categories. We reconstructed knee posture using an experimentally validated procedure of determining the anterior extent of the region of maximal subchondral bone apparent density on a median slice through the medial femoral condyle. We compared subchondral apparent density magnitudes between subfossil and extant specimens to ensure that fossils did not display substantial mineralization or degradation. Subfossil and extant specimens were found to have similar magnitudes of subchondral apparent density, thereby permitting comparisons of the density patterns. We observed significant differences in the position of maximum subchondral apparent density between leaping and nonleaping extant primates, with leaping primates appearing to use much more flexed knee postures than nonleaping species. The anterior placement of the regions of maximum subchondral bone apparent density in the subfossil specimens of Hadropithecus and Pachylemur suggests that both species differed from leaping primates and included in their broad range of knee postures rather extended postures. For Hadropithecus, this result is consistent with other evidence for terrestrial locomotion. Pachylemur, reconstructed on the basis of other evidence as a committed arboreal quadruped, likely employed extended knee postures in other activities such as hindlimb suspension, in addition to occasional terrestrial locomotion.

Knee Posture Predicted from Subchondral Apparent Density in the Distal Femur: An Experimental Validation

Spatial patterning in the apparent density of subchondral bone can be used to discriminate between species that differ in their joint loading conditions. This study provides an experimental test of two hypotheses that relate aspects of subchondral apparent density patterns to joint loading conditions. First, the region of maximum subchondral apparent density (RMD) will correspond to differences in joint posture at the time of peak locomotor loads; and second, differences in maximum density between individuals will correspond to differences in exercise level. These hypotheses were tested using three age-matched samples of juvenile sheep. Two groups of five sheep were exercised, at moderate walking speeds, twice daily for 45 days on a treadmill with either a 0% or 15% grade. The remaining sheep were not exercised. Sheep walking on the inclined treadmill used more flexed knee postures than those in the level walking group at the time of peak vertical ground reaction forces. Kinematic measurements of knee posture were compared with knee postures estimated from the spatial position of the RMD on the medial femoral condyle. Our results show that the difference in the position of the RMD between the incline and level walking groups corresponded to the difference in knee postures obtained kinematically; however, exercised and nonexercised sheep did not differ in the magnitude of apparent density. These results suggest that patterns of subchondral apparent density are good indicators of the experimental modifications in joint posture during locomotion and may, therefore, be used to investigate differences between species in habitual joint loading.

Reliability and concurrent validity of visual analogue scale and modified verbal rating scale of pain assessment in adult patients with knee osteoathritis in Nigeria

The objective of this study was to determine the reliability and concurrent validity of two pain rating scales - Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS). The verbal rating scale was modified by translating the English description of subjective pain experience into vernacular (Yoruba) equivalents and rating the knee pain when the patient was standing with the knee flexed . Twenty seven patients who were clinically and radiologically diagnosed with osteoarthritis (OA) and with knee pain were purposively selected for the study. Two testers (physiotherapists) independently rated the pain experienced by patients, when bearing full weight while standing on the affected leg with slight knee flexion, over a period of several days. For each patient pain was rated with the VAS and the modified VRS (MVRS). There were significant correlations between VAS and MVRS by the same tester (tester 1 and tester2) (r=0.92, p&lt;0.01; r = 0.89, p&lt;0.01respectively,)) and between VAS and MVRS between tester 1 and tester 2 (r=0.91,p&lt;0.01). There were no significant differences between VAS for tester 1 and VAS for tester 2, and between MVRS for tester 1and MVRS for tester 2 (p&gt; 0.01). According to this study, the two pain rating scales for knee OA are reliable. Our use of VAS and MVRS togetherwith the procedure involving the flexed knee posture is, therefore, recommended for wider clinical trials.

Contrasts in gait mechanics of individuals with proximal femoral focal deficiency: Syme amputation versus Van Nes rotational osteotomy.

Lower-limb kinematics and kinetics during preferred and fast speeds of walking were measured in persons with proximal femoral focal deficiency to compare outcomes after Syme amputation (nine subjects) with those after Van Nes rotational osteotomy (10 subjects). Subjects with a Van Nes rotational osteotomy and full tibial rotation (seven subjects) demonstrated prosthetic knee function during stance as they were able to support a flexed-knee posture at both speeds and produced greater knee-extensor moments at preferred speeds as compared with the Syme group (p < 0.05). Nonprosthetic limb compensatory mechanics were significantly exacerbated in subjects with a Syme amputation compared with the Van Nes group: (a) stance-phase vaulting, resulting in greater inappropriate ankle-power generation at both walking speeds, (b) excessive hip-extensor moments at fast speeds, (c) excessive hip-power absorption and generation at both speeds, and (d) excessive knee-joint power generation at both speeds (p < 0.05). The improved gait after Van Nes rotational osteotomy is one factor that should be considered when making clinical decisions for children with proximal femoral focal deficiency.

A REVIEW OF THE BIOMECHANICS AND EPIDEMIOLOGY OF WORKING POSTURES (IT ISN'T ALWAYS VIBRATION WHICH IS TO BLAME!)

Many vibrational environments also subject the worker to awkward, asymmetric and prolonged postures. This paper reviews the epidemiological, biomechanical and physiological factors involved in working postures which could lead to musculoskeletal problems. Too little or too much sitting leads to low back pain. Sedentary postures, including driving, also lead to a higher risk of a herniated disc. In sitting the pelvis rotates and higher pressures exist in the disk. A backrest inclined to 110° or more and with a lumbar support will reduce the disk pressure. Jobs involving excessive force application will be more apt to cause muscular and ligamentous damage. However, these excessive demands can occur in whole body vibration environments too. Neck, shoulder and arm problems are usually related to posture but can occur in WBV environments. Knee problems, in the standing worker, may be due to a flexed knee posture in an attempt to attenuate vibrations. Excessive postural demands on the neck, shoulder and arm will lead to higher muscle forces and higher joint forces. Recommendations are given to reduce risk of disability.

Evaluation of static work load in a helium-oxygen saturation dive at 31 ATA.

The purpose of the present study is to evaluate the static work load as a model work in Submersible Decompression Chamber (SDC) during a deep sea saturation dive with helium-oxygen gas mixture. Heart rate (HR) and electromyogram (EMG) power spectrum changes were studied during a 7-minute static work, half-rising posture or flexed knee posture in four healthy male subjects. During the static work, EMG of the rectus femoris was recorded with surface electrodes, and changes in the EMG power spectrum were presented in the ratio of a high-frequency to low-frequency band (H/L ratio) after the Fourier transform analysis. The HR decreased at 31 ATA and increased remarkably after the decompression to 1 ATA. HR at post-decompression was higher than pre-compression. The lowering phenomena of EMG presented by H/L ratios during the static work were similarly observed in all three conditions. But the changes of the high and low frequency components were different in the post-decompression condition from the pre-compression and 31 ATA conditions. HR as a parameter of static work load might underestimate the work load at the hyperbaric environment due to hyperbaric bradycardia and overestimate it after decompression by "decompression tachycardia." The EMG lowering phenomenon observed after decompression might not be caused by the same mechanism as seen in the pre-compression and hyperbaric environments. Extreme care must be taken to evaluate the static work load not only at hyperbaric helium-oxygen environments but after decompression from a deep saturation dive.

The effect of flexed knee posture on energy consumption

The effect of flexed knee posture on energy consumption

Ankle joint load and leg muscle activity in various working postures during machine milking.

Abstract Ten professional milkers simulated 20 different standardized machine-milking work postures. The loading moment of force about the bilateral ankle axis was calculated using a computerized biomechanical sagittal plane model. Leg muscular activity was recorded with time-averaged, full-wave rectified electromyography which was normalized. The muscular activity level was generally low. The calculated loading moment was always dorsifiexing and did not exceed 50 N m. This is not above 50% of the maximum strength capacity and is lower than the load during many daily activities. Straight knee working postures induced lower ankle load compared with flexed knee postures. The model for determining ankle load can be used to investigate similar activities.