Gait analysis post anterior cruciate ligament reconstruction: Knee osteoarthritis perspective
Highlights
► Analysis of stair use and walking in individuals post-ACL reconstruction (>1 year). ► Walking and stair use highlight altered joint loading post-ACL reconstruction. ► Reduced knee extension moments at least 1 year post-ACL reconstruction. ► Increased hip extension moments at least 1 year post-ACL reconstruction.
Introduction
Anterior cruciate ligament (ACL) injuries are among the most common musculoskeletal injuries, occurring frequently in young adults, especially women. Individuals younger than 30 years old sustain ACL ruptures more often as compared to the general population [1], [2]. ACL ruptures are often concurrent with meniscal injuries [2] and where combined injury has occurred, 48% of cases have evidence of knee osteoarthritis (OA) within 5–20 years after initial ACL injury [2], [3]. Therefore, individuals between 35 and 40 years old are at increased risk of knee OA following ACL rupture [1].
Structural changes associated with ACL injury combined with long-term changes in dynamic loading contribute to the development of knee OA [2]. As a measuring tool, gait analysis is considered a practical and reliable technique to indirectly assess dynamic loads on the lower extremity [4]. Investigating lower extremity kinetics during walking and stair negotiation can provide insight into everyday repetitive loads placed on the knee joint.
Arguably, external knee varus moments have the greatest clinical consequence when considering potential knee OA risk factors. Knee varus moments are associated with medial compression, the compartment most often affected with OA. Miyazaki et al. [5] established that the risk of knee OA progression increased by a factor of 6 with each 1% increase in knee varus moments. Attention has also focused on the role of the hip abductors in protecting against knee OA. Impaired hip abduction moment generation causes contralateral pelvis drop, increasing knee varus moments and medial compression [6], [7]. Hooper et al. [8] observed no differences in knee varus moments while walking or using the stairs when comparing the injured and non-injured leg one year post-ACL reconstruction. However, Butler et al. [9] observed 21% greater knee varus moments during walking in individuals five years following ACL reconstruction when compared to a control group. Increased knee varus moments may not be present within the first year of ACL rupture, but medial knee loading may increase as time progresses. Further study is required to assess whether dynamic knee joint loading is greater for individuals post-ACL surgery during walking and stair ambulation.
Sagittal lower extremity kinetic accommodations at the knee [8], [10], [11] and hip [8], [11], [12] have been reported following ACL reconstruction. Individuals 6–12 months post-ACL reconstruction have altered walking patterns as compared to controls, including reduced knee flexion angles at mid-stance [8], [11] and reduced knee extension moments during early stance [10], [11]. These gait adaptations may lead to degenerative changes in the articular cartilage by altering the loading patterns on the knee joint. Decreased knee flexion angles and knee extension moments have been associated with quadriceps weakness up to one year post-ACL surgery [13], [14]. Large cross-sectional studies have established strong relationships between quadriceps weakness and the onset of knee OA [15], [16]. Persistent quadriceps weakness developed through arthrogenic inhibition leads to altered kinetics and kinematics after knee injury [17]. Despite ACL reconstruction and aggressive rehabilitation regimes, weakness in quadriceps musculature exists up to one year post-ACL reconstruction surgery [18]. Theoretically, weak quadriceps musculature reduces the ability to generate the necessary force to provide efficient eccentric control during the loading phase of gait [17]. It has yet to be determined if quadriceps weakness along with reduced knee extension moments and knee flexion angles persist long-term (greater than one year after ACL reconstruction).
The purpose of this study was to analyze the gait of those with ACL reconstruction and a comparable healthy group during stair ascent, stair descent, and level walking. The primary focus was to determine if factors associated with the development and/or progression of knee OA were observed in the ACL reconstructed limb when compared to the non-injured limb and healthy counterparts. We hypothesized that the ACL reconstructed leg would display: (1) increased external knee varus moments, (2) reduced knee extensor strength, (3) reduced knee flexion angles, and (4) reduced knee extension moments when compared to the non-injured limb and control group.
Section snippets
Participants
Individuals >1 year from unilateral ACL reconstruction and healthy controls between 18 and 35 years old were recruited from a university setting. Exclusion criteria included history of any other musculoskeletal or neurological conditions precluding safe walking and stair negotiation. Control participants were excluded if they had a previous knee ligament injury or surgery. Our study aimed to match participants (i.e., age and sex) at group level. This study was approved by the Institutional
Methods
A 10 m walkway and a three-step staircase (step height 18.5 cm, tread depth 29.5 cm) were used. Kinematic data were collected using an 8-camera, three-dimensional motion analysis system (Vicon Nexus, Los Angeles, CA). Kinetic data were recorded using two portable force platforms positioned on the first and second step of the stairs and one in-ground force platform for level walking (AMTI, Watertown, MA). Kinematic data were collected at a sampling rate of 160 Hz, while force platform data were
Results
Overall, 19 people with unilateral ACL reconstruction and 17 healthy controls were examined. Due to equipment malfunction and numerical outliers, a subset of the cohort are presented for stair analysis (ACL = 14; control = 13) and walking analysis (ACL = 15; control = 17). There were no differences between the ACL group and controls for age, height, and body mass (Table 1). Furthermore, no differences in Tegner scores were found between the groups, verifying that all post-ACL individuals had returned
Discussion
This study aimed to determine if biomechanical parameters associated with the development and/or progression of knee OA existed >1 year post-ACL reconstruction. Knee injuries, including ACL ruptures, increase the risk for early-onset knee OA by 10-fold as compared to the general, uninjured population [20]. Focusing on repetitive movements such as stair use and walking in a post-ACL reconstruction cohort provides a good model to investigate the early onset of knee OA pathogenesis.
Contrary to our
Conflict of interest
The authors declare that there is no conflict of interest.
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2021, Physical Therapy in SportCitation Excerpt :Decreased knee loading after ACL-R can have deleterious effects on knee joint health and serve as a risk factor for re-injury (Ajuied et al., 2014; Kumar et al., 2018; Paterno, 2015). Decreased knee loading through asymmetry in sagittal plane movements has been identified during a variety of tasks at various time points during ACL-R rehabilitation (Baumgart, Schubert, Hoppe, Gokeler, & Freiwald, 2017; Bell, Kulow, Stiffler, & Smith, 2014; Boo et al., 2018; Castanharo et al., 2011; Di Stasi, Hartigan, & Snyder-Mackler, 2015; Ernst, Saliba, Diduch, Hurwitz, & Ball, 2000; Garrison et al., 2018, 2019; Hall, Stevermer, & Gillette, 2012; Labanca et al., 2016; Oberländer, Brüggemann, Höher, & Karamanidis, 2013; Pietrosimone et al., 2019; Pratt & Sigward, 2017; Renner, Franck, Miller, & Queen, 2018; Roos, Button, & Van Deursen, 2014; Sanford, Williams, Zucker-Levin, & Mihalko, 2016; Schmitt, Paterno, Ford, Myer, & Hewett, 2015; Sigward et al., 2016, 2018). At nearly 10 months post-operatively, patients who had undergone ACL-R displayed a significantly smaller knee extension moment during a single leg vertical jump compared to matched controls (Ernst et al., 2000).
Long-term gait biomechanics in level, uphill, and downhill conditions following anterior cruciate ligament reconstruction
2021, Clinical BiomechanicsCitation Excerpt :However the literature is inconsistent in individuals more than 1 year post-ACLR, as some studies report lesser sagittal moments and angles (Noehren et al., 2013; Patterson et al., 2014; Roewer et al., 2011) whereas others report no differences (Hall et al., 2012; Roewer et al., 2011; Webster et al., 2012; Zabala et al., 2013). Ambiguity also exists in the frontal plane more than 1 year post-ACLR with studies reporting greater (Butler et al., 2009), lesser (Patterson et al., 2014), or equivalent (Hall et al., 2012; Varma et al., 2014) peak frontal moments in the ACLR limb compared to controls. This inconsistency in the literature after the first year post-ACLR is potentially influenced by the task subjects perform.