Cairo University Faculty of physical therapy Neurology department

Research about: knee kinetic analysis

Under supervision of . .

Prepared by

Basic Kinetic Concepts 1. Mass Mass: - Quantity of matter composing a body - No mass = no mechanical identity - Symbol: m - Standard unit: kg (kilogram) Center of mass (COM) - a point around which the mass of a body is balanced in all directions 2. Force Force: - A push or pull acting on a body - Cause of motion - The main mechanical quantity of interest in kinetics - Symbol: F - Standard unit: N (Newton)

Properties: magnitude, direction & point of application Examples: muscle force, weight (gravity), friction, etc 3. Pressure Pressure: - Amount of force acting over a unit area: P=F/A - Standard unit: Pa (Pascal) = 1 N/m2

Examples: high-heel shoe, snow shoe, shin protector, etc.

Mechanical Loads on the Human Body 1. Types of loading Types: - Compression: pressing or squeezing force directed axially through a body - Tension: pulling or stretching force directed axially through a body - Shear: force directed parallel to a surface - Bending: asymmetric loading that produces tension on one side of a body's longitudinal axis and compression on the other - Torsion: load causing twisting of a body around its longitudinal axis

Combined loading: combination of different types of loading

Acute vs. repetitive: - Likelihood of injury: load magnitude vs. frequency

2. Mechanical Stress and Strain Mechanical stress: distribution of force inside of a solid body - Pressure: distribution of force external to solid a body - Examples: lumbar vs. thoracic vertebrae Strain: deformation due to stress

Load-deformation curve (stress-strain curve): - Yield point (elastic limit): permanent deformation - Failure point: loss of mechanical continuity

Kinetics
Kinetics is the general term given to the study of forces that cause movement. Force may be defined as a push or a pull and is produced when one object acts on another. The units used to measure force are Newtons (N). Forces in walking can be internal (such as muscle activity, ligamentous constraint, or friction in muscles and joints) or external (such as ground-reaction forces created from external loads).

Internal Moments
The rotational potential of the forces acting on a joint is called torque, moment or moment of force. The internal joint moment is the net result of all of the internal forces acting about the joint, including moments due to muscles, ligaments, joint friction and structural constraints. The joint moment usually is calculated around a joint center. When we think in terms of internal moments, for example, a net knee extensor moment means the knee extensors (quadriceps) are dominant at the knee joint, and the knee extensors are creating a greater moment than the knee flexors (hamstrings and gastrocnemius). The units used to express moments or torques are Newton-meters (N-m) and for research purposes usually are normalized to the subject's body mass. Normalization is the process by which a relationship is established between initially collected data (raw data) and some other basic reference data. Normalized to the subject's body mass, Newton-meters are expressed as N-m/kg. The term joint power is used to describe the product of a joint moment and the joint angular velocity. Joint power is said to be generated when the moment and the angular velocity are in the same direction and said to be absorbed when they are in opposite directions. The units used to measure joint power are Watts (W). Engineers and researchers studying gait attempt to measure the moment of force produced by muscles crossing a joint, the mechanical power flowing to and from those same muscles, and the energy changes of the body that result from this power. This requires the integration of both kinematic and kinetic data using very specialized data collection and processing systems.

External Moments
The external ground-reaction force line is a familiar concept to most clinicians trained in orthotics and prosthetics. Understanding its spatial relationship relative to the location of primary joints in normal gait is intuitively helpful in understanding the pathomechanics of a given patient. A reaction force is the force that an initial body (A) exerts on a second body (B) in response to a force exerted by B on A. The reaction force has equal magnitude but opposite direction relative to the force exerted on A by B. Ground-reaction force is comprised of three components: 1) vertical force, 2) fore-aft shear and 3) mediallateral shear. Information on these forces is obtained from a force platform or force

plate, which is a transducer set into the floor to measure the forces and torques applied by the foot to the ground These devices provide quantified measures of the three components of the resultant ground-reaction force vector and the resultant torque vector about a given joint. The ground-reaction force line essentially is the vector summation of the three reaction forces resulting from the interaction between the foot and ground. The moment of force or torque is the cross product of the radius vector and the force. The radius vector, traditionally assigned the variable r, is a position vector from the point around which the calculations are made to the line of action for the force being considered, traditionally assigned the variable F. The length of r is the moment arm of the force F. In two dimensions, the moment of force about a point is the product of a force and the perpendicular distance from the line of action of the force to the point. Typically, the moments of force are calculated about the center of rotation of a joint and are expressed in Newton-meters (N-m). We have seen the resultant ground-reaction force (GRF) vector is the mean load bearing line, which takes into account both gravity and momentum . It has magnitude as well as directional qualities. The spatial relationship between this line and a given joint center influences the direction in which the joint will tend to rotate. This has enormous implications in understanding what orthotic or prosthetic component or alignment variant might be used to stabilize a joint during ambulation. The groundreaction force line and the external moments or torques created at the major joints are presented in the pages that follow.

Electromyographics
Electromyographic (EMG) data provide important information in terms of understanding the direct physiological effect of prosthetic or orthotic design variants. Measuring muscle activity is like going straight to the mouth of the horse. Knowledge of the timing and intensity of the muscles throughout gait may suggest alterations in gait training and orthotic or prosthetic alignment or componentry to reduce excessive, ill-timed or prolonged muscle activity. Electromyographic information is obtained by inserting fine wire electrodes directly into the muscle belly or by placing noninvasive surface electrodes over the muscle apex. Wire electrodes have the advantage of precise placement and are less likely to register "cross-talk" from adjacent muscles. Wire electrodes are essential for measuring deep muscles. Surface electrodes provide a noninvasive alternative for measuring muscle activity of superficial groups

Functional Tasks of Gait

A complete gait cycle can be viewed in terms of three functional tasks of weight acceptance, single-limb support and limb advancement The first functional task is weight acceptance. Two phases of the stance period, initial contact and loading response, are involved in the performance of weight acceptance. The demand for immediate transfer of body weight onto the limb as soon as it contacts the ground requires initial limb stability and shock absorption while

simultaneously preserving the momentum of progression. When the functional task of weight acceptance has been achieved, the individual is said to demonstrate a stable kinetic chain. The second functional task is single- limb support. Primarily, two phases are associated with single-limb support: midstance and terminal stance. In addition, preswing is a transitional phase that could be considered part of single-limb support as well. During this period, the contralateral foot is in the swing period, and total body weight is exclusively supported on the stance limb. Forward progression of body weight over the stationary foot while maintaining stability is accomplished. The third functional task is limb advancement. Four phases contribute to limb advancement: preswing, initial swing, midswing and terminal swing. During these phases, the stance limb leaves the ground and advances forward to posture itself in preparation for the next initial contact. The preswing phase serves in both single-limb support and limb advancement.

Phases of Gait
The gait cycle can be described in the phasic terms of initial contact (IC), loading response (LR), midstance (MSt), terminal stance (TSt), preswing (PSw), initial swing (ISw), midswing (MSw) and terminal swing (TSw) The stance period consists of the first five phases: initial contact, loading response, midstance, terminal stance and preswing. The swing period primarily is divided into three phases: initial swing, midswing and terminal swing. Preswing, however, prepares the limb for swing advancement and in that sense could be considered a component of swing phase. Initial Contact Initial contact is an instantaneous point in time only and occurs the instant the foot of the leading lower limb touches the ground. Most of the motor function that occurs during initial contact is in preparation for the loading response phase that will follow. Initial contact represents the beginning of the stance phase. Heel strike and heel contact serve as poor descriptors of this period since there are many circumstances when initial contact is not made with the heel alone. The term "foot strike" sometimes is used as an alternative descriptor. Loading Response The loading response phase occupies about 10 percent of the gait cycle and constitutes the period of initial double-limb support. During loading response, the foot comes in full contact with the floor, and body weight is fully transferred onto the stance limb. The initial double-support stance period occasionally is referred to as initial stance. The term foot flat (FF) is the point in time when the foot becomes plantar grade. The loading response period probably is best described by the typical quantified values of the vertical force curve. The ascending initial peak of the vertical force graph reveals the period of loading response

Midstance Midstance represents the first half of single support, which occurs from the 10- to 30percent periods of the gait cycle. It begins when the contralateral foot leaves the ground and continues as the body weight travels along the length of the foot until it is aligned over the forefoot. The descending initial peak of the vertical force graph reveals the period of midstance Terminal Stance Terminal stance constitutes the second half of single-limb support. It begins with heel rise and ends when the contralateral foot contacts the ground. Terminal stance occurs from the 30- to 50- percent periods of the gait cycle. During this phase, body weight moves ahead of the forefoot. The term heel off (HO) is a descriptor useful in observational analysis and is the point during the stance phase when the heel leaves the ground. The ascending second peak of the vertical force graph demonstrates the period of terminal stance. Roll off describes the period of late stance (from the 40- to 50- percent periods of the gait cycle) when there is an ankle plantarflexor moment and simultaneous power generation of the triceps surae to initiate advancement of the tibia over the fulcrum of the metatarsal heads in preparation for the next phase. Preswing Preswing is the terminal double-limb support period and occupies the last 12 percent of stance phase, from 50 percent to 62 percent. It begins when the contralateral foot contacts the ground and ends with ipsilateral toe off. During this period, the stance limb is unloaded and body weight is transferred onto the contralateral limb. The descending portion of the second peak of the vertical force graph demonstrates the period of preswing . Terminal contact (TC), a term rarely used, describes the instantaneous point in the gait cycle when the foot leaves the ground. It thus represents either the end of the stance phase or the beginning of swing phase. In pathologies where the foot never leaves the ground, the term foot drag is used. In foot drag, the termination of stance and the onset of swing may be somewhat arbitrary. The termination of stance and the onset of swing is defined as the point where all portions of the foot have achieved motion relative to the floor. Likewise, the termination of swing and the onset of stance may be defined as the point when the foot ends motion relative to the floor. Toe off occurs when terminal contact is made with the toe. Initial Swing The initial one-third of the swing period, from the 62- to 75-percent periods of the gait cycle (6), is spent in initial swing. It begins the moment the foot leaves the ground and

continues until maximum knee flexion occurs, when the swinging extremity is directly under the body and directly opposite the stance limb. Midswing Midswing occurs in the second third of the swing period, from the 75- to 85-percent periods of the gait cycle (6). Critical events include continued limb advancement and foot clearance. This phase begins following maximum knee flexion and ends when the tibia is in a vertical position. Terminal Swing In the final phase of terminal swing from the 85- to 100-percent periods of the gait cycle (6), the tibia passes beyond perpendicular, and the knee fully extends in preparation for heel contact. Analysis of the Gait Cycle - Joint Position 1. Heel Strike a. Ankle joint = is in a neutral position. That is, it is neither dorsiflexed nor plantar flexed b. Knee joint = flexed Weight of body behind knee Slight flexion helps absorb the impact of the foot contacting the ground from impact between b. Hip joint flexed i. Lengthens limb in preparation for contact between heel and ground. Helps provide for proper placement of foot so that the heel make contract with the ground. b. Foot = supinated Midstance i. ii.

2.

a. Ankle joint = dorsiflexed b. Knee joint = extended lengthens limb to help support weight of torso which is now directly over limb b. Hip joint = Neutral c. Foot = Slight pronation 2. Toe Off a. Ankle joint = plantar flexed i. triceps surae ( superficial muscles in posterior compartment of leg) begin to contract strongly bringing the ankle joint into a plantar flexed position b. Knee joint = flexed i.

i.

contraction of the gastrocnemius muscle , one of thew triceps surae muscles, causes active flexion of the knee joint ii. shorten limb to allow clearance from ground b. Hip joint = Extended Torso on the opposite side has moved forward of reference limb b. Foot = supinated Acceleration

i. 2.

a. Ankle joint = neutral b. Knee joint = flexed i. i. shorten limb to maintain foot off of the ground b. Hip joint = flexed Limb catches up to and then passes the torso b. Foot = slight pronation

MUSCLE ACTIVITY DURING GAIT INTERVAL JOINT POSITION MUSCLE ACTIVITY Flexed Gluteus Maximus Hamstrings Gluteus medius & minimus Knee Ankle Heel Strike to Midstance Hip Knee Ankle Tarsal Flexed Neutral Neutral Extended Dorsiflexed Inverted Quadriceps femoris Anterior crural muscles Gluteus medius & minimus Quadriceps femoris Gastrocnemius; soleus Tibialis anterior Tibialis posterior Midstance to Toe Off Hip Knee Ankle Extended Flexed Plantar flexed Gastrocnemius Gastrocnemius; soleus

Acceleration to Heel Hip Strike

Tarsal

Everted

Fibularis longus Fibularis brevis

Toe Off to Acceleration

Hip

Flexed

Iliopsoas Adductors longus, brevis, magnus

Knee Ankle Tarsal

Flexed Neutral Neutral

Gastrocnemius Anterior crural muscles -

Pathological Gait
Weakness Insufficient force output by muscles may result from disuse, primary muscle disease, or neurologic impairment. Substitution of impaired motor function frequently is possible, and reduction of walking velocity further reduces demand on muscles. Muscle force requirements are trivial in normal individuals. Less than 25% of normal strength (manual muscle test grade 3+/5) is needed for locomotion. In cases of disease, with decreased maximum muscle force, functional reserve is lost. Endurance is compromised, and community-level ambulation may not be possible. Selective loss of muscles (or muscle groups) is demonstrated by characteristic gait patterns. In each case, orthotic management is targeted at preventing excessive motion. Uncompensated calf weakness results in diminished mid stance control of the forwardly rotating tibia. Substitution for calf weakness is difficult. The increased amount and rate of dorsiflexion increases the functional demands on the quadriceps to maintain limb stability. Alternatively, tibial advancement is curtailed with resultant genu recurvatum, decreasing the work of the quadriceps. Unfortunately, this gait alteration frequently initiates knee joint pathology. Other compensatory maneuvers include reducing step velocity and step length. The consequence of pretibial muscle weakness is increased plantar flexion. With mild weakness, foot slap occurs during loading response. With more extensive dorsiflexion weakness, foot drop and toe drag are observed during swing phase. Compensation is achieved through circumduction of the ipsilateral limb, increased ipsilateral knee plus hip flexion, and hip hiking of the contralateral limb. Each of these tendencies assists in swing-phase toe clearance. Of these compensations, circumduction is the most energy efficient and most commonly observed technique for dorsiflexor insufficiency. Quadriceps weakness diminishes knee control, and deficits in stance are most pronounced. External forces tend to hyperflex the knee, and a variety of compensations are employed to preserve stability in weight bearing. Compensations begin prior to weight acceptance (late swing) and continue through that limb's support

activity. Late swing hip flexion leads to passive knee extension through momentum transfer. Stance phase increased knee flexion is attenuated by hip extension and premature plantar flexion. Alternatively, external rotation of the affected limb orients the external force vector medial to the joint axis, minimizing the tendency toward knee flexion. Isolated hamstring weakness is an uncommon gait deficit. Isolated hip flexor weakness is uncommon. Clinical presentation includes decreased walking velocity or decreased hip range of motion. Reduction of hip extensor forces, which may be secondary to paralysis or muscle lengthening, leads to increases in anterior pelvic tilt during stance. Hip adductor weakness results in pelvic instability during stance. External forces (ie, torso mass) lead to frontal plane rotation about the ipsilateral hip joint. This contralateral tilt normally is resisted by eccentric contraction of ipsilateral hip abductors (ie, gluteus medius, minimus). Shifting the torso over the ipsilateral hip joint in mid stance (Trendelenburg gait) minimizes the force required by the hip abductors. This gait pattern, which limits contact forces between femur and acetabulum, also is observed in hip joint pathology. Spasticity Spasticity results from lesions of the CNS. The primary lesion may be in the brain or spinal cord, although multiple lesions along the neuraxis also are possible. Spasticity may involve the upper and lower extremities. Although arm swing does have some effect on gait and is altered with spasticity, discussion of gait alterations resulting from upper extremity spasticity is beyond the scope of this analysis. In the lower extremity, a few common patterns emerge, including the equinovarus foot, valgus foot, striatal toe, stiff (extended) knee, flexed knee, adducted thighs, and flexed hip. Equinovarus is the most common spasticity-related pathology seen in the lower extremity. Toe curling (clawing) may coexist. Contact is at the forefoot, with weight acceptance along the lateral aspect of the foot. Skin breakdown along the lateral border of the foot may be an associated problem. Equinovarus posturing limits single support dorsiflexion, prevents forward progression of the tibia, and leads to a hyperextension thrust of the knee and restrained forward translation of the body's center of mass. This abnormality compromises stability by decreasing the base of support and may prevent functional ambulation. Swing phase foot clearance is compromised. Muscles that may contribute to this disorder include tibialis posterior, tibialis anterior, long toe flexors, medial and lateral gastrocnemius, soleus, extensor hallucis longus, and peroneus longus. Conservative management includes administration of neurolytic and chemodenervation agents. Tendon lengthening decreases force output with no change in neural drive. Valgus foot results from inappropriate contraction of peroneal and triceps surae muscles. Stance phase stability is compromised by an abnormal base of support. This condition also may lead to genu valgum stresses and resultant pathology to medial knee joint structures.

Persistent great toe hyperextension (hitchhiker toe) is not uncommon. Selection of footwear is complicated. The usual offender is the extensor hallucis longus (EHL) muscle. This pathology often is managed successfully with motor point block of the EHL muscle. Diagnostic blocks often are helpful if co-contraction by the flexor hallucis longus is suggested. Stiff knee, a frequent complication of stroke, is a severe hindrance during swing. Overactivity by iliopsoas, gluteus maximus, quadriceps, and hamstrings (as hip extensors) is a possible contributor to this condition. Functional deficits include increased effective limb length, with circumduction, contralateral vaulting, or hiking of the pelvis required for foot clearance. Energy consumption is increased, typically in patients with little functional reserve. Kinesiologic EMG analysis may be required to identify the contributing muscle(s) from the extensive aforementioned list. Crouched gait is marked by excessive knee flexion in both swing and stance. Limb advancement is attenuated as part of this crouch pattern. Both hamstring and quadriceps muscles may be involved. Kinesiologic EMG may demonstrate prolonged activity of the medial hamstrings. Knee flexion contracture is common. Excessive hip flexion may interfere with multiple activities of daily living and may contribute to knee flexion deformity. Again, excessive hip flexion may interfere with limb advancement in swing, as well as decreased advancement of the center of mass over the flexed support limb. Initial treatment of both excessive knee and hip flexion is controversial. Therapeutic interventions include motor point blocks, chemoneurolysis, tendon lengthening, tendon transfers, and muscle release. Thigh adduction (ie, scissoring) may interfere with daily activities, as well as with gait. Limb advancement is curtailed by severe hip adduction. Balance may be impaired as a result of a narrowing of the base of support. Muscles that potentially contribute to gait scissoring include the adductor longus and brevis, adductor magnus, and gracilis. Less frequently, the iliopsoas and pectineus are contributors. Diagnostic obturator nerve block helps establish whether contracture is present. Contractures Plantar flexor contracture of 15 is most common. This joint position minimizes joint capsule tensile forces. Contracture may be rigid or elastic. Only the ankle orientation at initial contact and mid swing is altered with elastic contractures. Despite that fact, limb advancement may be slowed, because of the viscoelastic nature of tissues. A rigid 15 contracture is associated with early foot flat and lack of early stance phase tibial advancement. Decreased toe clearance and foot drag are swing phase consequences. Dorsiflexion contractures are rare, although sometimes they are observed in lumbar-level myelomeningocele (present anterior tibialis and absent triceps surae). Knee joint contractures are typically at 30 of flexion. This position correlates with the resting position of the swollen knee. Only initial swing is affected by this posturing. Step length is shortened as a result of decreased knee extension in terminal swing, and metabolic demands are increased. Knee extension contractures (ie, capsule scarring) diminish limb advancement in early swing phase.

Hip flexor contractures result from shortening of hip flexor muscles or the joint capsule. A tight iliotibial band is a variant of this disorder. Each results in increased forward pelvic tilt. Loss of hip joint flexion due to hip extensor contracture is infrequent. Pain Pain does not inhibit normal motion directly; however, deformity and weakness may result from the person's attempts to attenuate pain through gait modifications. The positions of maximal joint capsule and ligamentous laxity typically are adopted. Generally, joint reaction forces are magnified with increases in muscle forces crossing the joint, and increased joint contact force is associated with increased discomfort. One mechanism for reduction of joint pain is to limit the muscle force output at the painful joint. This protective response leads to muscle atrophy and weakness. Sensory loss Impaired proprioception inhibits walking because of diminished information about the limb segment positions in space. When sensory loss predominates (intact motor control), initial contact may be emphasized. Superimposed motor losses diminish the individual's ability to make rapid substitution efforts, resulting in decrements in walking velocity and stability.

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