A deficient anterior cruciate ligament does not lead to quadriceps avoidance gait

doi:10.1016/S0966-6362(99)00038-7

Gait & Posture

Volume 10, Issue 3, December 1999, Pages 189-199

https://doi.org/10.1016/S0966-6362(99)00038-7 Get rights and content

Abstract

Without an intact anterior cruciate ligament (ACL) to resist anterior tibial translation, it is commonly believed that ACL-deficient patients employ alterations in walking. Although there is no consensus in the literature about the specific kinematic and kinetic adaptations in these patients with ACL tears, the gait adaptation of quadriceps avoidance is perhaps the one most popularized. The purpose of our study was to determine whether quadriceps avoidance is common in patients with ACL-deficiency. We used a video-based motion analysis system and surface electromyography (EMG) to study 18 patients with ACL-deficiency. All patients demonstrated an internal knee extension moment during early mid-stance (similar to normal subjects). Quadriceps EMG activity was noted throughout most of stance. No patients demonstrated an internal knee flexion moment, a decreased internal knee extension moment or a decreased duration of quadriceps EMG activity during stance. The findings of this study would suggest that quadriceps avoidance as a gait adaptation in ACL-deficient patients may be less common than previously reported.

Introduction

The anterior cruciate ligament (ACL) is commonly injured and patients with ACL tears have been reported to demonstrate various alterations in walking [1], [2], [3]. Berchuck et al. [3] popularized the concept of quadriceps-avoidance, an external extension moment at the knee in stance in the ACL-deficient patients, as an attempt to decrease anterior shear forces on the tibia. However, other investigators have been unable to reproduce the phenomenon of quadriceps avoidance (an external knee extension moment) in ACL-deficient patients.

Kadaba et al. [4] reported a flexed knee pattern combined with external knee flexion moments, rather than a quadriceps avoidance pattern in unreconstructed ACL-deficient patients. Patients in the post-operative period after ACL reconstruction with a patellar tendon autograft from the extensor mechanism, where it would be expected that quadriceps avoidance would be easily observable, have not demonstrated this adaptation [5]. Snyder-Mackler et al. [6] reported kinematic alterations consistent with a co-contraction strategy of the quadriceps and hamstrings in the early postoperative phase after ACL reconstruction. Beard et al. [7] reported an increase in the duration of hamstring activity with similar quadriceps activity duration while exhibiting external flexion moments at the knee in ACL-deficient subjects with respect to controls.

Our first purpose was to corroborate previous studies in this area regarding the phenomenon of an increased internal flexion moment during stance (quadriceps avoidance) in a population of patients with ACL tears. This was done using a video-based motion analysis system and surface electromyography (EMG). Our second purpose was to determine if there are any other mechanisms, besides decreased quadriceps muscle activity, that might account for any observed internal flexion moment or decreased internal extension moment in stance.

Section snippets

Subjects

A complete medical history was obtained from each patient. All patients were interviewed and a comprehensive lower extremity physical examination (which included ligament testing, range of motion, manual muscle testing and observation of gait) was conducted by the primary author using a modified Cincinnati Knee Rating System [8].

The 18 subjects of this study had a unilateral ACL-deficiency. All patients had a positive Lachman’s sign and a grade two or three pivot shift maneuver (Table 1). In

Results

Typical clinical gait analysis kinematic plots (ensemble averaged for all subjects) are shown in Fig. 1 (stride side) and Fig. 2 [non-stride side (termed opposite side in this paper)]. Saggital view stride side moment and power plots (ensemble averaged for all subjects) are shown in Fig. 3. Except for the stride and opposite side knee plots and the opposite side ankle plots, the ensemble averaged kinematic and kinetic plots fall within the ±1 S.D. plots of the normal subjects.

None of the

Discussion

We did not find a significantly different knee kinematic or kinetic pattern in early stance or a decreased duration of quadriceps activity in any ACL-deficient subject. We expected to find quadriceps avoidance in at least some of our subjects. Berchuck et al. [3] reported that 75% of their patients with ACL tears had a flexed knee gait and absence of an extension moment. Noyes et al. [8] found quadriceps avoidance in 50% of patients with ACL-deficiency and varus alignment. Birac et al. [13] in

Acknowledgements

Funding for this study was made possible through a grant from the Jewish Hospital Foundation, Louisville, KY. Additionally, the authors wish to thank Dr Terry Horn, Dr Murali Kadaba and Dr Peter Quesada for their review and editorial comments related to this manuscript.

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Knee flexion angle and muscle activations control the stability of an anterior cruciate ligament deficient joint in gait
2021, Journal of Biomechanics
Anterior cruciate ligament (ACL) is a primary structure and a commonly injured ligament of the knee joint. Some patients with ACL deficiency (ACLD) experience joint instability and require a reconstructive surgery to return to daily routines, some can adapt by limiting their activities while others, called copers, can return to high-level activities with no instability. We investigated the effects of alterations in the knee flexion angle (KFA) and muscle force activations on the stability and biomechanics of ACLD joints at 25, 50, and 75% periods of gait stance. ACLD joint stability is controlled by variations in both KFA and knee muscle forces. For the latter, a parameter called activity index is defined as the ratio of forces in ACL antagonists (quadriceps and gastrocnemii) to those in ACL agonists (hamstrings). Under a greater KFA (2–6° beyond the mean of reported values in healthy subjects), an ACLD joint regains its pre-injury stability levels. The ACLD joint stability also markedly improves at smaller quadriceps and larger hamstrings forces (activity indices of 2.0–3.6 at 25%) at the first half of stance and smaller gastrocnemii and larger hamstrings forces (activity indices of 0.1–1.1 at 50% and 0.1–1.2 at 75%) at the second half of stance. Activity index and KFA are both crucial when assessing the dynamic stability of an ACLD joint. These results are helpful in our understanding of the biomechanics and stability of ACLD joints towards improved prevention and treatment strategies.
Changes in gastrocnemii activation at mid-to-late stance markedly affects the intact and anterior cruciate ligament deficient knee biomechanics and stability in gait
2021, Knee
We aimed to quantify the sensitivity in biomechanical response and stability of the intact and anterior cruciate ligament deficient (ACL-D) joints at mid-to-late stance periods of gait to the alterations in activation of gastrocnemii (Gas) muscles.
A validated kinematics-driven musculoskeletal finite-element model of the lower extremity is used to compute knee joint response and stability under reported kinetics–kinematics of healthy subjects. Activation in Gas is altered under prescribed gait data at the mid-to-late stance of gait and associated changes in remaining muscle forces/contact forces/areas/ACL force and joint stability are computed in both intact and ACL-D joints.
In the intact joint, the anterior-tibial-translation (ATT) as well as ACL and joint contact forces follow variations in Gas forces. Both the stability and ATT of an ACL-D joint are restored to the near-intact levels when the activity in Gas is reduced. Knee joint instability, excessive ATT as well as larger peak articular contact stresses with a posterior shift in contact areas are estimated under greater Gas forces.
ACL-D joint is unstable with ATT > 10 mm under larger activities in Gas. Gas is an ACL-antagonist while hamstrings and soleus are ACL-agonists. The near-intact joint stability and ATT of an ACL-D joint can be restored at a lower activation in Gas; or in other words, when activation in ACL-antagonist muscles drops compared with that in ACL-agonist muscles. Results could help analyze the gait of ACL-D copers and non-copers and provide better understanding towards improved preventive, diagnostic, and treatment approaches.
Gait Analysis Comparing Kinematic, Kinetic, and Muscle Activation Data of Modern and Conventional Total Knee Arthroplasty
2020, Arthroplasty Today
To provide normal knee function, a total knee arthroplasty (TKA) implant with an anatomic surface shape and an adequate sagittal position has been developed. However, it is unclear how this modern implant influences knee joint kinetics and muscle activation during a gait. Therefore, we evaluated this modern TKA prosthesis and compared it with a conventional TKA prosthesis for gait analysis in terms of kinetics and muscle activation.
Subjects were patients (>60 years of age) with knee osteoarthritis who had undergone unilateral TKA. Twelve patients received the modern TKA prosthesis (group modern), and the other 12 patients received a conventional TKA prosthesis (group conventional). The subjects underwent motion capture analyses with a force plate, and kinematic and kinetic data were acquired from a 10-m gait test. Electromyography data of 6 lower limb muscles were simultaneously collected during the gait test. The 2 groups were compared using unpaired t-tests.
In group modern, gait speed was faster, step length was longer, and the knee flexion angle during the initial stance phase was larger. Furthermore, in group modern, the maximum knee extension moment was higher; however, the quadriceps muscle activity tended to be lower than that in group conventional.
Gait characteristics of group modern were more like a normal gait, and knee joint extension moments were greater. This finding indicates that the quadriceps muscles can be more effectively activated, and the anterior stability function of the anterior cruciate ligament may be reproduced with the shape of the modern implant.
Foot and ankle compensation for anterior cruciate ligament deficiency during gait in children
2020, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Ankle kinematics were not significantly different between the two groups. In 18 patients with anterior knee instability, Roberts et al. [21] found no reduction in the internal knee extension moment. They concluded from their findings that the quadriceps avoidance pattern as a gait adaptation to ACL deficiency may be less common than previously reported.
Anterior cruciate ligament (ACL) injuries are common in adults and cause knee instability, pain, and an increased risk of osteoarthritis. Previous studies demonstrated changed gait patterns in adult patients with ACL deficiency. In paediatric patients, ACL injuries were once thought to be rare but are being increasingly diagnosed due to greater involvement of children in contact sports and to the introduction of more effective diagnostic tools such as magnetic resonance imaging (MRI). However, little is known about gait adaptation in children with ACL deficiency. The objective of this study was to look for compensatory foot and ankle behaviours during gait in paediatric patients with symptomatic ACL deficiency.
Compensation for ACL deficiency during gait occurs at the foot and ankle in children, because compensation at the hip and pelvis would require greater energy expenditure.
We included 47 patients, 33 males and 14 females, ranging in age from 9 to 17 years (mean, 14.1 years). The patients had a history of unilateral ACL injury documented by MRI and initially treated by immobilisation and physical therapy. They were allowed to walk with full weight-bearing on the affected limb and were not taking medications at the time of the study. All patients had pain, knee instability, or functional limitation. The physical examination showed joint laxity indicating surgical ACL reconstruction. None had neurological conditions, congenital musculoskeletal abnormalities, or a history of knee surgery. Gait analysis (GA) was performed using a Vicon 460 system. Kinematic data for the ankle and foot were compared to those in a control group of 37 healthy children. Ankle angular positions were calculated for each group at the following stance time points: initial contact (0% of gait cycle [GC]), mid-stance (25% GC), terminal stance (60% GC), and swing (83% GC). Foot progression data were recorded at mid-stance (25% GC) and swing (70% GC). Student's t test was applied to compare the results to reference values obtained at our laboratory and to data from the control group.
Compared to the reference values, the ankle was in plantar flexion at initial contact in 41 patients, and ankle dorsiflexion during the stance phase was diminished in 39 patients. The external foot progression angle was increased in 23 patients during the stance phase and 38 patients during the swing phase. Compared to the control group (mean age, 9.1 years), the patients had plantar flexion of the ankle at initial contact (3.43° ± 3.5° vs. 0.74° ± 3.6°, p < 0.05) and decreased dorsiflexion during the stance phase (3.43° ± 3.5° vs. 0.74° ± 3.6°, p < 0.05). No significant differences were found for any of the other parameters.
Children with ACL deficiency developed compensatory foot and ankle behaviours during gait that improved knee stability. Understanding these compensations may guide treatment optimisation.
III, retrospective comparative study.
Foot and ankle compensation for anterior cruciate ligament deficiency during gait in children
2020, Revue de Chirurgie Orthopedique et Traumatologique
La rupture du ligament croisé antérieur (LCA) est de plus en plus fréquente chez l’enfant. L’objectif de notre étude était d’évaluer les modifications de la marche des enfants avec une lésion du LCA, et surtout les adaptations de la cheville et du pied à l’instabilité du genou.
Les enfants compensent l’instabilité antérieure du genou pendant la marche par des adaptations au niveau de la cheville et du pied, car la compensation au niveau de la hanche et du bassin nécessite une dépense importante d’énergie.
Quarante sept patients (14 filles, 33 garçons) âgés de 9 à 17 ans (âge moyen 14,1) avec une lésion unilatérale du LCA ont été analysés. La lésion du LCA était confirmée par IRM et traitée initialement par immobilisation et rééducation. Tous les patients étaient symptomatiques, avec sensation d’instabilité du genou. Une analyse quantifiée de la marche (AQM) a été réalisée avec étude de la cinématique de la cheville (en appui et en phase oscillante) et de la progression plantaire. Les données des patients ont été comparées à la référence de notre laboratoire et aux valeurs d’un groupe de 37 enfants sains (analyse statistique teste t).
Par rapport à la référence du laboratoire : la cheville était en flexion plantaire (FP) à l’attaque du pas pour 41 patients. La flexion dorsale (FD) du pied était diminuée pour 39 patients en phase d’appui. La progression plantaire en rotation externe était augmentée pour 23 patients en phase d’appui et pour 38 patients en phase oscillante. Par rapport au groupe des patients sains : les enfants avec lésion du LCA marchaient en FP de cheville à l’attaque du pas (3,43° ± 3,5 vs 0,74° ± 3,6, p < 0,05) et FD diminuée en phase d’appui (3,43° ± 3,5 vs 0,74° ± 3,6, p < 0,05). Pour le reste des paramètres, il n’y avait pas de différence significative.
Les enfants présentant une instabilité antérieure du genou ont développé des compensations au niveau de la cheville et du pied qui permettent une meilleure stabilisation du genou. La compréhension de ces adaptations pourrait être utile dans le traitement de cette pathologie.
III. Étude rétrospective comparative.
Classification of gait muscle activation patterns according to knee injury history using a support vector machine approach
2019, Human Movement Science
Citation Excerpt :
However, long-term adaptations in muscle activation patterns past the first few years after knee injury are not well characterized and vary widely between studies (Hall, Stevermer, & Gillette, 2015; Limbird, Shiavi, Frazer, & Borra, 1988; Lindström, Felländer-Tsai, Wredmark, & Henriksson, 2010; Roberts, Rash, Honaker, Wachowiak, & Shaw, 1999), which hinders an analysis of their relationship with knee osteoarthritis. For example, Roberts and colleagues observed abnormal timing of muscle activity for the quadriceps and hamstrings muscles but not for lower leg muscles during the stance phase of gait in ACL-deficient individuals at 47 months post-injury (Roberts et al., 1999). In contrast, Lindström and colleagues showed differences in on-offset timing of the tibialis anterior and gastrocnemius but no differences for the thigh muscles between ACL-deficient individuals and a control group at 35 months post-injury (Lindström et al., 2010).
Abnormal muscle activation patterns during gait following knee injury that persist past the acute injury and rehabilitation phase (>three years) are not well characterized but may be related to post-traumatic knee osteoarthritis. The aim was to characterize the abnormal muscle activity from electromyograms of five leg muscles that were recorded during treadmill walking for young adults with and without a previous knee injury 3–12 years prior. The wavelet transformed and amplitude normalized electromyograms yielded intensity patterns that reflect the muscle activity of these muscles resolved in time and frequency. Patterns belonging to the affected or unaffected leg in previously injured participants and patterns belonging to a previously injured vs. uninjured participant were grouped and then classified using a principal component analysis followed by a support vector machine. A leave-one-out cross-validation was used to test the model significance and generalization. The results showed that trained classifiers could successfully recognize whether muscle activation patterns belonged to the affected or unaffected leg of previously injured individuals. Classification rates of 83% were obtained for all subjects, 100% for females only, indicating sex-specific knee injury effects. In contrast, it was not possible to discriminate between patterns belonging to the previously injured legs or dominant legs of control subjects. For females, the injured leg showed a stronger muscle activity for hamstring muscles and a lower activity for the vastus lateralis. In conclusion, systematic knee injury effects on the neuromuscular control of the knee during gait were present 3–12 years later.

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A deficient anterior cruciate ligament does not lead to quadriceps avoidance gait

Abstract

Introduction

Section snippets

Subjects

Results

Discussion

Acknowledgements

Gait Post.

J. Hum. Move. Sci.

J. Electromyogr. Kinesiol.

J. Biomech.

J. Biomech.

J. Electromyogr. Kinesiol

The course of knee ligament injuries

Acta Orthop. Scand. Suppl.

Gait adaptations by patients who have a deficient anterior cruciate ligament

J. Bone Joint Surg.

Gait adaptation patterns in patients with ACL deficiency

Trans. Orthop. Res. Soc.

Return of normal gait patterns after anterior cruciate ligament reconstruction

Am. J. Sports Med.

Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament

J. Bone Joint Surg.