Stride-to-stride variability of knee motion in patients with knee osteoarthritis

doi:10.1016/j.gaitpost.2005.06.003

Gait & Posture

Volume 23, Issue 4, June 2006, Pages 505-511

https://doi.org/10.1016/j.gaitpost.2005.06.003 Get rights and content

Abstract

Purpose

Individuals with knee osteoarthritis (OA) experience pain, frontal plane joint laxity and instability. Co-contraction can control laxity and instability but may place constraints on the variability of the knee's motion during gait. Slight variation among gait cycles is normal, but reduced variability of joint motions could be detrimental. The purpose of this study was to quantify knee motion variability during gait and assess the influence of muscle activity, frontal plane laxity, and pain on knee movement variability in patients with medial knee OA.

Methods

Fifteen subjects with unilateral medial knee OA and 15 age and gender matched uninjured subjects underwent gait analysis, with electromyography to compute co-contraction. Stress radiographs were obtained for measuring frontal plane laxity. Knee motion variability was assessed from the phase angle (knee angle versus angular velocity) during early stance.

Results

Despite altered involved side knee kinematics and kinetics, individuals with knee OA showed involved side frontal plane variability which was not significantly different from the control group, but was significantly lower than the variability of the uninvolved knee's motion. Laxity and medial co-contraction influenced the amount of joint motion variability in the involved knee of the OA subjects. Pain did not influence variability.

Conclusion

Patients with medial knee OA displayed altered involved knee kinematics and kinetics, although stride-to-stride variability of knee motion was unchanged. Evidence of excessive joint motion variability on the uninvolved side, however, may provide insight into the development of OA in the contralateral cognate joint.

Introduction

Knee osteoarthritis (OA) is marked by the progressive erosion of articular cartilage, subchondral sclerosis, and osteophyte growth at the joint margins. Patients may also experience ligamentous laxity, muscle weakness, joint instability, and debilitating pain [1].

Joint pain in patients with knee OA can provoke a stereotypical knee-stiffening pattern during gait [2], [3]. The measurement of joint angles at discrete time points provides valuable information, yet may represent an incomplete analysis because it ignores the inherent variability involved in the completion of a movement task. Uninjured subjects perform successive cycles (e.g. steps, strides) of rhythmic movements, such as gait, in a similar, but not identical manner with each repetition [4]. This is because the inherent redundancy of the motor components allows for multiple solutions to joint coordination in order to achieve the same control of the foot's path. The variability of joint motions may therefore reflect flexibility of movement patterns used to achieve control of important performance variables. We are particularly concerned with the variability of the knee joint's motion during gait, which we define as the stride-to-stride variability of the knee's angular position and velocity with each step.

Individuals with knee OA could potentially experience knee joint damage or pain due to the presence of either too much or too little knee motion variability. An increase in knee joint motion variability could indicate inadequate control of the joint. Conversely, a substantial reduction in knee motion variability could lead to an inability to adequately adjust to perturbations and attenuate impact shocks [5]. Additionally, joint surfaces would undergo similar stresses with each repetition, potentially leading to articular cartilage destruction. Therefore, the use of sufficient, but not excessively varied joint motions with each repetition may aid in the redistribution of stress across the joint [6].

Individuals with knee OA may reduce the variability of the knee joint's motion for several reasons. Pain could contribute to the overuse of similar, less painful knee joint motions [6] which may further damage a joint that has already begun to undergo structural and biochemical alterations. Radin and coworkers [7] speculated that progressive cartilage erosion was due to the continuous repetitive microtrauma that the joint undergoes on a daily basis. In vitro animal experiments have confirmed that cyclic loading of articular cartilage contributes to breakdown [8], [9]. A failure to use more varied joint motions could therefore theoretically accelerate the degeneration of the articular surface. Perhaps a better explanation, however, is that the development of frontal plane laxity may lead to joint instability, requiring increased muscular control to stabilize the joint [10], [11]. Individuals with medial knee OA attempt to stabilize the knee during gait with greater medial co-contraction, resulting in reduced joint excursions [12] and perhaps less varied knee joint motions.

The purpose of this study was to quantify the variability of knee motion in patients with medial knee OA. Our hypothesis was that patients with medial knee OA would demonstrate reduced variability of the knee's frontal and sagittal plane motions during gait compared to their uninvolved knees or the knees of a matched control group. In addition, we expected that pain, frontal plane joint laxity, and muscular co-contraction during gait would provide insight into the mechanism underlying alterations in knee motion variability.

Section snippets

Subjects

Fifteen patients (6 females, 9 males; age: 48.7 ± 7.4 years, height: 1.75 ± .09 m, weight: 91.9 ± 17.4 kg) with unilateral symptomatic, medial compartment knee osteoarthritis and genu varum (OA group) scheduled for high tibial osteotomy were tested. The diagnosis of OA was made from the clinical history, a physical examination, and radiographic changes observed during standing with the knees flexed to 30°. These radiographs showed definite joint space narrowing in the medial compartment (medial

Joint kinematics and kinetics

The OA and control subjects walked at a velocity of 1.37 ± 0.13 and 1.44 ± 0.16 m/s, respectively (p = 0.219). The knee flexion excursion during weight acceptance was significantly less on the OA group's involved side (9.6 ± 4.4°) compared to the uninvolved side (15.4 ± 5.2°; p = 0.003) or controls (14.7 ± 3.6°; p = 0.002). The involved knee extension moment at peak knee flexion was 0.124 ± 0.186 N mm/kg m, which was significantly less than the uninvolved knee extension moment of 0.281 ± 0.166 N mm/kg m (p = 0.005) and the

Discussion

The hypothesis that the involved limb of patients with medial knee OA would demonstrate less varied knee motion during gait was partially supported by these data. The frontal plane variability of the involved limb was significantly lower than the variability of the uninvolved knee but not different from the control group. Frontal plane knee laxity and medial co-contraction partially influenced the amount of joint motion variability in the involved knee in individuals with unilateral knee OA.

Acknowledgements

The authors would like to acknowledge the assistance of Darcy Reisman, Ph.D., P.T. William Newcomb, MD, Laura C. Schmitt, P.T. Daniel Ramsey, Ph.D., and Laurie Andrews, RTR. Funding was provided by the American College of Sports Medicine (Doctoral Student Research Grant), National Institute of Health (1P20RR016458, 2T32HD007490), the Foundation for Physical Therapy (PODS II), and EBI Medical, L.P.

References (24)

J. Hamill et al.
A dynamical systems approach to lower extremity running injuries
Clin Biomech (Bristol, Avon)
(1999)
M. Thibault et al.
Cyclic compression of cartilage/bone explants in vitro leads to physical weakening, mechanical breakdown of collagen and release of matrix fragments
J Orthop Res
(2002)
P.A. Torzilli et al.
Continuous cyclic load reduces proteoglycan release from articular cartilage
Osteoarthritis Cartilage
(1998)
M.D. Lewek et al.
Control of frontal plane knee laxity during gait in patients with medial compartment knee osteoarthritis
Osteoarthritis Cartilage
(2004)
D.T. Felson et al.
Osteoarthritis: new insights. Part 2: Treatment approaches
Ann Intern Med
(2000)
N.M. Fisher et al.
Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation
Disabil Rehabil
(1997)
S.P. Messier et al.
Osteoarthritis of the knee: effects on gait, strength, and flexibility
Arch Phys Med Rehabil
(1992)
M.T. Turvey
Coordination
Am Psychol
(1990)
B.C. Heiderscheit
Movement variability as a clinical measure for locomotion
J Appl Biomech
(2000)
E.L. Radin et al.
Relationship between lower limb dynamics and knee joint pain
J Orthop Res
(1991)

G.K. Fitzgerald et al.

Reports of joint instability in knee osteoarthritis: its prevalence and relationship to physical function

Arthritis Rheum

(2004)

L. Sharma et al.

Laxity in healthy and osteoarthritic knees

Arthritis Rheum

(1999)

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Citation Excerpt :
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16 individuals with moderate medial compartment knee OA, 16 individuals with moderate hip OA, and 16 asymptomatic controls were recruited. Participants walked on a treadmill while segment kinematics and ground reaction forces were recorded. Sagittal plane kinematics and sagittal and frontal plane moments were calculated. Surface electromyograms were recorded from lateral and medial hamstrings and gastrocnemius and vastus lateralis and medialis. Discrete variable analysis was used to investigate knee joint mechanics and muscle activation ratios. Analysis of Variance models using Bonferroni corrections determined between group differences (α = 0.0167).
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Stride-to-stride variability of knee motion in patients with knee osteoarthritis

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Subjects

Joint kinematics and kinetics

Discussion

Acknowledgements

Clin Biomech (Bristol, Avon)

J Orthop Res

Osteoarthritis Cartilage

Osteoarthritis Cartilage

Osteoarthritis: new insights. Part 2: Treatment approaches

Ann Intern Med

Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation

Disabil Rehabil

Osteoarthritis of the knee: effects on gait, strength, and flexibility

Arch Phys Med Rehabil

Coordination

Am Psychol

Movement variability as a clinical measure for locomotion

J Appl Biomech

Relationship between lower limb dynamics and knee joint pain

J Orthop Res

Reports of joint instability in knee osteoarthritis: its prevalence and relationship to physical function

Arthritis Rheum

Laxity in healthy and osteoarthritic knees

Arthritis Rheum