Beruflich Dokumente
Kultur Dokumente
Sylvie Nadeaua, Denis Gravel* a, Luc J. HCbertb, A. Bertrand Arsenaulta, Yves LepageC
Research Center, Montreal Rehabilitation Institute and School of Rehabilitation, Faculty of Medicine, University of Montreal,
6300 Darlington Ave., Montreal, Quebec, H3S 2J4. Cam&
bH6pital aes Forces Arm&es Canadiennes de Valcartier, Q&bee, Canaak
=Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
Abstract
Patellofemoral pain syndrome is a frequent knee impairment in young adults. This study investigated the kinematic and kinetic
gait patterns of individuals suffering from patellofemoral pain syndrome (PFPS). It was hypothesized that PFPS subjects modify
their gait pattern in order to reduce loading on the painful patellofemoral joint. To verify this, the gait pattern of five subjects
with right chronic PFPS was compared with that of five healthy subjects. Spatiotemporal, kinematic and kinetic data were collected
from five gait cycles. The joint moments at the hip, knee and ankle joints were calculated using an inverse dynamic approach and
the values were normalized to body weight (N-m/kg). Individual joint moments were expressed as a percentage of the support
moment in order to quantify possible compensatory strategies. The kinematic analysis revealed a significant reduction of the knee
flexion angle (ANOVAs, P < 0.01) occurring at lO%, 20% and 70% of the gait cycle. There were no significant differences between
the two groups of subjects (ANOVAs, P > 0.05) as far as the individual joint moments and their contribution to the support
moment were concerned. However, modifications were observed in the knee and hip moments between loo/oand 20% of the gait
cycle. These modifications may suggest that PFPS subjects alter their gait pattern in order to reduce loading of the patellofemoral
joint to avoid pain.
demonstrated that 75% of patients presenting an ante- patellar subluxation and no systemic or orthopaedic
rior cruciate ligament deficiency showed a reversed knee pathology. A control group of two healthy men and
joint moment (from extension to flexion) associated three healthy women were also selected in order to
with an increased hip extensor moment at the beginning match the PFPS group on the basis of their anropo-
of the stance phase. These authors stated that in- metric data. The mean age of this group was 25.5
dividuals with an anterior cruciate ligament instability (f 13.3) years. The groups mean height and weight
reduce the utilization of the knee extensors to avoid were 1.70 (~0.07) m and 67.0 (~8.6) kg, respectively.
anterior displacement of the proximal end of the tibia on All subjects gave their informed consent prior to partici-
the femur. Similarly, Winter [ 151 reported that patients pation in the study.
with a total knee replacement have a net flexor moment
at the knee joint during most of the stance phase. He 2.2. Assessment
also noted a concomitant increase of the extensor Two types of assessments were performed: (I) a clini-
moments at both the hip and ankle joints. cal assessment performed on the involved and uninvolv-
The increase in the hip extensor moment reported in ed limbs of the PFPS subjects and (II) a walking
the above studies can be interpreted as a muscular com- assessment collected on the right lower limb for all
pensation resulting from the underuse of the knee exten- subjects.
sor muscles. The support moment concept described by (Z) Clinical assessment. Girth measurements were
Winter [ 151 provides a framework to demonstrate such taken at the knee joint level (interarticular line) as well
compensations carried out in this case by the hip exten- as at 5, 10 and 20 cm above the knee joint. Active range
sors. Within this concept, the collapse of the lower ex- of motion (ROM) was assessedby goniometry while the
tremity during weight bearing is prevented by the subjects were asked to bend and extend their knees as
extensor muscles of the hip, knee and ankle joints. much as possible. The Q angle [5] was determined by
Mathematically, the net support moment (MS) during videography with markers placed on the anterior superi-
the stance phase is defined as Ms = Mx - MA - Mu or iliac spinous process, patellar centre and anterior
where M,, MA and MH represent the moments at the tibial tuberosity. The Q angle is defined as the angle be-
knee, ankle and hip joints, respectively. Using the con- tween the extension of a line from the anterior iliac spine
vention that positive moments are created by the knee to the centre of the patella and a line joining the tibia1
extensors and negative ones are generated by the hip ex- tuberosity to the centre of the patella. The normal values
tensors and plantarflexors, these muscle groups would are C 15 in males and ~20 in females [a]. At the
contribute positively to Ms. Thus, according to the beginning and at the end of the experimental session,
above equation, a lower contribution of the knee exten- knee pain was evaluated using a visual analogue scale
sor muscles to the support moment could be compen- (VAS;[ 191). Knee status of the involved limb was graded
sated by a larger participation of the hip extensor using the Tegner and Lysholm questionnaire [20]. This
muscles in order to produce the same support moment. questionnaire includes items concerning activities of
The objective of this study was to examine the gait daily living and knee symptoms (locking, swelling, insta-
pattern of PFPS patients walking at a preferred speed in bility and pain) and has a maximum score of 100, in-
order to determine if they presented kinematic and ki- dicating normal function.
netic alterations during gait. We hypothesized that a (ZZ) Walking assessment. The subjects were instructed
smaller knee flexion angle with a reduction in the knee to walk naturally on a 9-m walkway equipped with a
extension moment would be compensated by an increase force platform (AMTI OR6-5-1). Five walking cycles
in the hip extensor and/or plantarflexor moments during were collected on the right lower extremity for each sub-
the stance phase in PFPS subjects. ject using a Peak Performance videographic system.
Stride characteristics were recorded with three foot-
2. Metbodology contacts located on the sole of the footwear, i.e. at the
heel, metatarsal heads and first toe. The force platform
2.1. Subjects was used to record vertical (Fz), anteroposterior (Fy)
Two groups of subjects were evaluated during level and mediolateral (Fx) components of the external forces
walking at preferred speed. The PFPS group included and the corresponding moments.
two men and three women with a mean ( f S.D.) age of Circular reflective markers were placed on the lateral
28.4 (h7.5) years. They had a mean height and weight projection of the limbs axis. These markers identified
of 1.72 ( f 0.06) m and 67.6 ( f 8.2) kg, respectively, and the fifth metatarsophalangeal joint, lateral malleolus,
presented chronic right PFPS diagnosed by an or- knee joint flexionlextension axis (2.5 cm above the knee
thopaedic surgeon. The duration of the PFPS ranged joint line) and the hip joint flexion/extension axis (3.0
from l-7 years. These participants were selected accord- cm above greater trochanter). A marker was also posi-
ing to the following criteria: chronic anterior knee pain, tioned to identify the heel. The subjects position in the
no previous knee surgery and/or traumatic injury, no sagittal plane was recorded by a video camera
S. Nudcau et ~1. I Gait & Posture 5 (1997) 21-27 23
(Panasonic, WV-DSlOO) placed 4.9 m from the [23] were applied to localize the sites of these differences
walkway. The video camera operated at a frequency of thus contrasting, at a given percentage of the gait cycle,
30 Hz. The force data and film sequences were syn- the data obtained for both groups. An a! level of signiti-
chronized by means of an electric impulse and a simulta- cance of 0.05 was selected for all statistical tests.
neous light which was captured on the film. The
foot-contacts and platform signals were sampled at a 3. Results
frequency of 120 Hz with a data-acquisition card (Data
Translation, model DT2821). 3.1. Clinical assessment
The Student t-tests did not reveal the presence of any
2.3. Data analysis significant differences between the involved and unin-
The Peak Performance system was used to digitize volved limbs of the PFPS subjects for any of the clinical
marker positions. The precision of the automatic variables assessed (Table 1). The average Q angle was
digitalization methods of this system is acceptable for slightly higher for the involved limbs than that of the
gait analysis, that is, l/38 18 mm horizontally and l/3 137 uninvolved limbs (30.7 vs. 24.1). None of the subjects
mm vertically for a marker of 38 mm in diameter [21]. reported the presence of pain during the session. Knee
The x and y coordinates obtained were smoothed, for- assessment, using the Tegner and Lysholm question-
ward and backward, with a second order digital Butter- naire, produced a mean result of 69.8 ( f 12.6).
worth filter, using a cut-off frequency between 2 and 8
Hz as determined by a residual analysis of each marker 3.2. Walking assessment
[22]. Following this, angular positions were determined Spatiotemporal parameters did not differ significantly
from proximal and distal coordinates and finite differen- between groups (Table 1). The average angular
tial procedures were applied to determine velocities and displacements for the hip, knee and ankle joints are
accelerations. The same procedures were applied to lin- shown in Fig. 1. The ANOVA revealed the presence of
ear displacements. A dynamic analysis was performed significant differences between groups in the angular
on body segments, and joint moments at the ankle, knee displacement of the knee joint (ANOVA, P = 0.0047).
and hip joints were calculated. Spatiotemporal, kin- According to the Tukeys test, the knee flexion was
ematic and kinetic calculations were carried out using significantly lower for the PFPS group as compared
computer programs developed at our Centre.
In order to compare the results between subjects and
groups, gait cycles were normalized (100%). All
moments were also normalized to body weight Table 1
(N . m/kg) [22]. The mean values were calculated at each Mean values (*SD.) of the clinical assessment and spatiotemporal
2% interval of the gait cycle and these values were used parameters
to estimate each moments contribution to the support Clinical assessment PFPS f-test P-value
moment. To quantify the compensation, moments at all
three joints were expressed in relation to their contribu- Uninvolved Involved
tion to the support moment. For example, the ankle (left) bh3m
joints contribution (CM,& in percentage, is given by: ROM knee
Flexion (9 141.0 (3.6) 143.0 (3.4) -1.00 0.35
Extension () 3.2 (4.1) 3.4 (3.7) -0.08 0.94
MS-WK-MH) x 1oo
CM, = Girth measures (cm)s 51.4 (3.0) 49.6 (2.8) 0.41 0.60
MS Q angle 24.1 (8.2) 30.7 (8.4) -1.27 0.24
TLb 69.8 (12.6)
2.4. Statistical analysis Spatiotemporal Groups t-test P-value
Students t-tests were used to determine between- parameters
group differences for the values of spatiotemporal vari- Control PFPS
ables of the gait cycle and to detect differences in the (n = 5) (?I = 5)
clinical variables between the involved and uninvolved Cadence (step/mitt) 103.7 (6.9) 101.3 (8.3) 0.50 0.63
limbs of the PFPS subjects. PFPS and control group dif- Stride length (m) 1.4 (0.1) 1.5 (0.2) -0.04 0.97
ferences were evaluated by two-way ANOVAs with re- speed Ws) 1.3 (0.2) 1.2 (0.2) 0.21 0.84
peated measures using results obtained at each 10% of Single support (%) 59.0 (2.2) 58.7 (2.2) 0.52 0.61
the gait cycle as the repeated measure factor. This Swing (%) 40.7 (1.9) 41.5 (2.2) -0.62 0.63
Double support (%) 19.6 (3.8) 18.8 (3.6) 0.33 0.75
statistical procedure was applied to the joint angles, the
ground reaction forces, the muscular moments and to Girth measures: the values reported are those taken at 20 cm above
their respective contribution to the support moment. the knee joint level.
When significant differences were found, Tukeys tests ?L: Tegner and Lyshom questionnaire.
24 S. Nudrtiu et al. I Gait & Posture 5 (1997) 21-27
-100 4
-2 1 4 10 16 22 28 34
0 20 40 60 80 100 % OF STRIDE
% OF STRIDE
Fig. 3. Contribution of the hip (CM), knee (CMK) and ankle (CM,)
Fig. 2. Support moment and muscular moments at the hip, knee and to the support moment for the control (-) and the PFPS (-C)
ankle for the control (-) and the PFPS (-C) groups. groups.
S. Nudeuu et ul. I Gait & Posture 5 (1997) 21-27 25
muscular compensations were not depicted. The patient the variability in the data, greater differences between
assessed in Winters study [ 151 had a IO-year history of groups are required to observe statistically significant
pathology and the patients with unstable anterior results in the joint moments as compared with joint
cruciate ligaments observed by Berchuck et al. [ 181were angles. An additional reason, which could explain the
candidates for surgery. In contrast to those subjects, our lack of statistical differences in knee and hip extensor
PFPS subjects did not experience any pain during expcr- moments, is the possibility that the initial compensatory
imentation and were not candidates for surgery. Thus, strategy used by most PFPS subjects, is a modification
it is possible that PFPS patients use muscular compensa- of their kinematic patterns. The changes in joint
tions only when the task is more demanding. moments could appear later on within the illness process
Since the statistical analyses indicated that knee flex- and/or only in a few subjects because kinematic changes
ion angle is the important variable characterizing PFPS fail to relieve pain.
subjects, it is relevant to discuss its significance. In other
knee pathologies, authors have reported that knee flex- 5. Conclusion
ion during the stance phase in gait is related to clinical
findings. In general, greater knee flexion during stance The present study compared the gait patterns of five
is observed in patients having more involvement of the PFPS subjects with those of five normal subjects. The
affected knee. With a greater stance knee flexion, it is objectives of the study were to evaluate the changes in
impossible to have a low extensor moment at the knee kinematic and kinetic parameters of gait in subjects suf-
during gait [32]. In studies of patients following knee ar- fering from chronic PFPS and also to determine if PFPS
throplasty, it was found that subjects having a good subjects had developed muscular compensations. Re-
range of motion in extension actually reverse the exten- sults revealed a decrease in the knee tlexion angle but
sor knee moment to a flexor one during the stance phase failed to reveal significant kinetic changes in the gait
[32]. Furthermore, some studies [ 15,181 which have pattern. Nevertheless, considering the limited number of
reported a reversed knee moment, also revealed a larger subjects and the wide between-subjects variability, we
hip extensor moment; probably to provide a more nor- believe that the trends observed in the knee moment, hip
mal support moment. In the present study, at the begin- moment compensations and ground reaction forces fur-
ning of the stance phase, we found a significant decrease ther support the presence of gait adaptation to the
in knee flexion in PFPS subjects. This decrease was underlying knee pathology in individuals with
associated with a concomitant decrease in the average patellofemoral pain syndrome.
knee extensor moment and a small increase in the aver-
age hip extensor moment. These results could support
the fact that a smaller knee flexion, in addition to reduc- Acknowledgments
ing the mechanical demand on the knee extensor mus-
cles, promotes the compensations noted in the hip This research was supported by grants from the
extensor moment. These findings could be considered as Fonds de la Recherche en Sante du Quebec and the Na-
a possible strategy used by the PFPS subjects to reduce tional Defense of Canada. The authors would like to
loading on the painful patellofemoral joint. This could thank Mr. Michel Goyette for his participation in data
be an alternative explanation to the lack of pain: PFPS collection and processing. During the course of the pres-
subjects may have learned to compensate to avoid the ent study, S. Nadeau was supported by a M.Sc. scholar-
onset of pain. However, further studies with a larger ship from the Fonds pour la Formation de Chercheurs
amount of subjects are needed before definitive conclu- et 1Aide a la Recherche. D. Gravel is a research fellow
sions can be made. from the Fonds de la Recherche en Sante du Quebec.
The results of the knee joint angle were statistically This work was also supported by the National Defence
significant while those of the knee joint moment were of Canada.
not. A possible explanation of this finding could be the References
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