Lower-Limb Coordination Responses to Knee Bracing in Females with Anterior Knee Pain
Citation: Wyatt HE,
Jewell C, Weir G, Boyer KA, Hamill J (2018) Lower-Limb Coordination Responses
to Knee Bracing in Females with Anterior Knee Pain. Sports Injr Med 2: 139.
DOI: 10.29011/2576-9596.100039
Abstract
Background: Anterior Knee Pain (AKP) during
running has been partially attributed to lower-limb kinematics. Mechanical
deviances from asymptomatic cohorts at the hip, knee, shank and foot have been
reported for joints and segments in isolation. Appraisal of lower-limb
coordination and its variability may provide important insight into the role of
proximal and distal lower-limb joint and segment couplings during running with
AKP. The extent to which current knee bracing strategies (standard-fit and
custom-fit) for pain moderation influence lower-limb couplings may assist in
the development of empirically informed recommendations for AKP management. The
aim of this study was to investigate lower-extremity kinematic couplings of AKP
participants during running without bracing and when wearing standard- and
custom-fit knee braces.
Methods: Eighteen
females (nine AKP, nine asymptomatic) performed ten running trials at a fixed
speed (3.2 m·s-1) in a custom-fit
knee brace, a standard-fit knee brace and no brace. Three-dimensional
unilateral lower-limb kinematics data were obtained from which, joint and
segment angles were calculated. Hip-knee, knee-ankle, thigh-shank and
shank-foot coordination and coordination variability were determined using a
modified vector coding technique.
Results: AKP participants spent less time in
knee internal rotation-dominant couplings (P < 0.05) and a greater
proportion of stance in ankle eversion-dominant couplings (P = 0.01; ES =
0.62). Frontal plane hip-knee couplings were found to differ for AKP
participants when wearing standard- and custom-fit braces (P = 0.04; ES =
0.39). Overall, bracing conditions had the greatest influence on the
asymptomatic cohort. No coordination variability differences were found between
groups or conditions.
Discussion: Participants
with AKP ran with different lower-limb coordination strategies than their
asymptomatic counterparts. Localized joint bracing (standard- and custom-fit)
did not oppose the coupling mechanics found in the AKP cohort when running in
the unconstrained condition. It is therefore suggested that pain management
strategies which consider the whole limb may be more effective than knee braces
alone.
Keywords: Coordination
Variability; Joint Coordination; Running; Segment Coordination; Vector Coding
1. Introduction
Anterior Knee Pain (AKP) is a common
manifestation of Patellofemoral Pain Syndrome (PFPS) for which incidence rates
have been documented to be 2.23 times greater for females than males [1]. Typically aggravated by increased
patellofemoral joint compressive force, AKP primarily occurs during repetitive
locomotor activities such as running [2]. The high prevalence of AKP in active populations
are reported to be partially attributed to intrinsic biomechanical mechanisms
including lower extremity malalignment, muscular imbalance and abnormal
movement patterns [3].
A wealth of research has been
dedicated to further understand the altered joint and segment kinematics
strategies used by AKP cohorts during running. Biomechanical insight has
exposed the multi-segmental nature of AKP development through its associations
with hip, knee, shank and foot mechanics [4-9]. However, conflicting evidence has resulted from
the analyses of isolated joint and segment mechanics, indicating the potential
benefit of adopting an approach which considers the interaction of joints and
segments in furthering understanding of AKP mechanics during running.
A dynamical systems approach to
appraise the interaction of individual degrees of freedom in accordance with
Bernstein’s principles [10] is anticipated to expose valuable insight
which may be masked by isolated joint and segment analyses. The coordination of
adjacent joints during a movement pattern has etiological associations with
injury [11],
whereas inter-segmental coupling may offer advanced understanding on the
control of multiple degrees of freedom to achieve individual joint motion.
Initial insight into lower-limb couplings of
PFPS cohorts have revealed shank-rearfoot [12], shank-knee [13] and knee-rearfoot [13] differences with asymptomatic cohorts during
running. Understanding of proximal lower-limb couplings inclusive of the thigh
segment and hip joint in addition to distal ankle coupling strategies may
assist the advancement of pain management, prevention and rehabilitation strategies
for individuals with AKP.
Within asymptomatic individuals, joint
and segment coordination variability enables stable structures to move with
sufficient flexibility for adaptation to perturbations [14]. Lower levels of joint and segment
coordination variability throughout locomotion indicate the potential for
overuse injury risk development due to repetitive stress on consistent
structures [14,15]. As has been shown through the
exploration of inter-segmental variability [14], understanding of the variability of joint and
segment coordination during locomotion may expose underlying contributing
mechanisms to AKP.
With the aim of correcting
biomechanical deficits that may contribute to pain, knee bracing is a low-cost
resource which can be worn during locomotion activities. In addition to pain
reduction, a primary purpose of the knee brace is to promote joint stability [16] for which, a well-fitting knee
orthosis is crucial. Different types of knee-braces can be broadly categorized
as standard-fit (offered in limited sizes) and custom-fit (tailored fit using
anthropometric measures). Altered lower-limb kinematics have been reported with
the use of a hinged knee brace, including reductions of peak hip and knee
flexion during running [17]. Understanding the influence of knee brace design
on inter-joint and inter-segmental movement patterns may be advantageous in
directing the focus of AKP management and prevention strategies (e.g. the
extent to which multiple joints should be considered). Bracing is predominantly
used to support painful or injured joints but can also be used as an injury
prevention strategy for healthy cohorts. The distinct roles of knee bracing
between populations are indicative of the need for braces
to have a greater biomechanical influence on symptomatic populations (e.g.
AKP), with reduced biomechanical influence on asymptomatic individuals.
Therefore, the aim of this study was
to investigate lower-extremity kinematic couplings of AKP participants during
running without bracing and when wearing standard- and custom-fit knee braces.
Based on previous biomechanical analyses of independent and coupled lower-limb
joints and segments, it was hypothesized that runners with AKP would utilize
different coupling patterns and have lower coordination variability than their
asymptomatic counterparts. As modification of functional joint stability is a
primary objective of knee bracing, it was further hypothesized that the AKP
cohort would have different coordination and coordination variability responses
to standard-fit, custom-fit and no brace conditions, while knee bracing would
have no significant effect on coupling mechanisms in the asymptomatic cohort.
2. Methods
2.1. Participants
Eighteen habitual female rearfoot
runners participated in this study (nine asymptomatic and nine AKP). The
asymptomatic group had a mean age, height and mass of 22.1 ± 2.6 years, 1.67 ± 0.07 m and 58.6 ± 7.3 kg, respectively. The mean
age, height and mass for the AKP group was 22.7 ± 6.0 years, 1.69 ± 0.08 m and 62.0 ± 8.8 kg, respectively. AKP participants were
recruited based on a self-reported visual analog scale, which indicated pain
and discomfort at the knee after performing daily activities. All participants
signed an informed consent document approved by the Institutional Review Board
of the University of Massachusetts, Amherst.
2.2. Data Collection
Participants completed two laboratory
visits; informed consent and procedural details were outlined within the first
session, in addition to the performance of mock trials to confirm participants could achieve the required running speed.
Biomechanical data were collected during the second visit. Participants ran
along a 30 m runway at a set speed of 3.2 m·s-1 measured
by two timing gates 6 m apart. Ten successful running trials were collected in
three conditions: no brace, standard-fit brace and a custom-fit brace. Trail
success was determined by completion within ± 5% of the specified speed. Fitting of
the standard-fit brace consisted of a selection of standard sizes and alignment
of the patellar with the brace patellar opening. The custom-fit brace was
positioned and fitted in accordance to the guidelines outlined by the
manufacturer using above- and below-knee measurements. Trials were completed in
a blocked randomized order for which participants wore standard lab-supplied
running shoes. All participants were determined to be rearfoot strikers through
inspection of sagittal plane foot kinematics and vertical ground reaction
forces.
Unilateral lower-limb kinematic data
were captured at 240 Hz using an 11-camera motion capture system (Oqus 3,
Qualisys Inc., Gothenburg, Sweden). For asymptomatic participants, data were
collected for the right leg; data for the AKP participants were collected from
the symptomatic leg. Retro-reflective markers were placed at the pelvis (left
and right anterior superior iliac spine, posterior superior iliac spine and
iliac crests), thigh (four marker cluster placed laterally), shank (four marker
cluster placed laterally), forefoot (hallux, 1st metatarsal head and 5th metatarsal base) and rearfoot
(superior, lateral and medial aspects of the calcaneus). Femoral greater
trochanters and lateral and medial femoral condyle and malleolus markers were
additionally attached for use within a static calibration trial, which was
undertaken without knee bracing. Qualisys Track Manager (QTM) (Qualisys, Inc.)
software was used to synchronize kinematic data with a 1.2 x 0.6 m force plate
at 1200 Hz (AMTI, Watertown, MA). The force plate was embedded in the runway
and was used for identification of heel strike and toe-off events.
2.3. Data
Processing and Analysis
Markers were identified and tracked
using QTM, within which, temporarily occluded markers were interpolated using a
polynomial spline. Three-dimensional marker coordinate date were imported to
Visual 3D software (C-Motion Inc., Rockville, MD). Using static trial
positional data, the lower extremity was modelled as a rigid, linked-segment system
inclusive of the pelvis, thigh, shank and foot segments. The ankle and knee
joint center positions were calculated as the mid-point between the medial and
lateral joint markers. The hip joint center was calculated as the mid-point
between the right greater trochanter marker and the pelvis-distal marker
(calculated as the mid-point between the right and left greater trochanters).
Marker coordinate data were filtered using low-pass bi-directional Butterworth
filters at 8 Hz. A 10 N threshold was used to determine heel strike and toe-off
events from vertical ground reaction force profiles. Angular data for hip, knee
and ankle joints and thigh, shank and foot segments were calculated with Cardan
angles with an X-y-z rotation sequence and normalized to 101 points for the
stance phase (heel strike to toe-off).
Normalized angle data were input to a
custom MATLAB program (Math Works Inc., Massachusetts, USA) for
each trial and each participant. Using a modified vector coding technique [18],
coupled joint angles (hip-knee and knee-ankle) were derived for each condition
(standard-fit, custom-fit and no brace), in addition to segment angle couplings
(thigh-shank and shank-foot) which were computed relative to a fixed laboratory
orthogonal coordination system (Table 1). Ranging from 0° to 360°, coupling angle outcomes have been
previously interpreted through division into eight categories with combinations
of in-/anti-phase and distal-/proximal-dominancy [19]. Divided by group and condition, frequency analyses
were conducted for each coupling across stance, representing the duration of
the coupling angle in each of the eight categories. Using a circular statistics
approach, coordination variability was calculated for each coupling as outlined
by Chang et al. [18].
2.4. Statistical
Analysis
Following normality testing of
coupling angle frequency data (P < 0.05), a Mann-Whitney U test was
performed to explore the differences between AKP and asymptomatic cohorts
within the no brace condition. Friedman’s repeated measures ANOVA test enabled
the statistical appraisal of within group, between conditions frequency
statistical differences. Pairwise comparisons were performed with a Bonferroni
correction for multiple comparisons. All discrete statistical analyses were
conducted using SPSS software (IBM SPSS Statistics 23, SPSS Inc., Chicago, IL).
Effect Sizes (ES) were calculated from z statistics outputs [23] and interpreted in accordance to
Cohen’s large (0.8), moderate (0.5) and small (0.2) boundaries [24].
Based on random field theory,
One-Dimensional Statistical Parametric Mapping (SPM1D) enabled the statistical
analysis of the continuous data outputs [25]. Following normality testing (P < 0.05), a
non-parametric two-sample t-test was performed to appraise the between group
coordination variability differences. To assess the between conditions, within
group coordination variability differences
across the stance phase, a non-parametric repeated measures ANOVA was
additionally performed. To further investigate any significant coordination
variability difference between conditions, non-parametric two-sample t-tests
were conducted. An alpha criterion of 0.05 was set a priori.
3. Results
3.1. Influence
of AKP on Coordination and Variability During Running
Hip-knee and knee-ankle couplings were
found to be significantly different for AKP and asymptomatic cohorts during
stance (P < 0.05; ES > 0.5; Figure 1). For HRot-KRot coupling (Figure 1a), AKP participants spent a reduced
proportion of stance with anti-phase, knee-dominant coordination (hip external
rotation/knee internal rotation) in comparison with asymptomatic participants
(11% frequency difference; P = 0.01; ES = 0.64). Analyses of KRot-AInv/Eve (Figure 1b) revealed greater anti-phase,
ankle-dominance (knee external rotation/ankle eversion) for the AKP cohort (P =
0.01; ES = 0.62). AKP participants additionally spent significantly more time
in anti-phase, knee-dominance (knee internal rotation/ankle inversion) than
their asymptomatic counterparts (11% frequency difference; P = 0.01; ES =
0.59). No statistically significant coordination variability differences were
found between the AKP and asymptomatic cohorts.
3.2. Influence
of Knee Bracing on Coordination and Variability
Significant coordination differences
were revealed for AKP participants for HAdd/Abd-KAdd/Abd and TRot-SRot, and
asymptomatic participants for KRot-AInv/Eve, TRot-SRot and SRot-FInv/Eve couplings
(P < 0.05; Fig. 2). Participants spent a significantly greater time with in-phase hip-dominance
(hip adduction/knee adduction) coupling when wearing a standard-fit brace, in
comparison with a custom-fit brace (2% difference; P = 0.04; ES = 0.39; Figure
2a). Although TRot-SRot differences
were identified for the AKP cohort between the three bracing conditions, no
paired differences were found (P > 0.05; Figure 2b). KRot-AInv/Eve coupling analyses revealed that when
wearing no brace, asymptomatic participants spent significantly more time with
in-phase ankle-dominance (knee external rotation/ankle inversion) in comparison
with the standard-fit brace (2% difference; P = 0.04; ES = 0.39; Figure
2c). The asymptomatic
cohort additionally spent a significantly greater proportion of stance with
in-phase, shank-dominant coordination (thigh external rotation/shank external
rotation) when wearing no brace (16 ± 8%) in comparison with the
standard-fit brace (9 ± 8%; P = 0.01; ES = 0.44; Figure
2d) and the
custom-fit brace (9 ± 6%; P = 0.04; ES = 0.39). For SRot-FInv/Eve,
custom-fit bracing significantly increased the duration asymptomatic
participants spent in anti-phase foot-dominant (shank external rotation/foot
eversion) in comparison with the standard-fit (P = 0.04; ES = 0.39) and no
brace conditions (P = 0.00; ES= 0.50; Figure 2e). The asymptomatic cohort spent
longer in anti-phase shank-dominance (shank external rotation/foot eversion)
when in the no brace condition (P = 0.00; ES = 0.56) in comparison with the
standard-fit and custom-fit brace conditions.
Significant coordination variability differences were found for AKP KRot-AInv/Eve (P < 0.05; Figure 3). At 10% of stance, AKP group KRot-AInv/Eve variability was greatest for the no brace condition (8.9°), in comparison with the standard-fit (6.0°) and custom-fit (7.3°) conditions. Further exploration revealed no paired significant differences between KRot-AInv/Eve conditions.
4. Discussion
The purpose of the current study was to investigate lower-extremity kinematic couplings for AKP participants during running without bracing and when wearing standard- and custom-fit knee braces. It was firstly hypothesized that AKP participants’ coordination and coordination variability would differ from their asymptomatic counterparts. The AKP cohort had different HRot-KRot and KRot-AInv/Eve coordination patterns across stance; however, no group differences were identified for coordination variability. The first hypothesis was subsequently supported in part. It was additionally hypothesized that coordination and coordination variability would differ between standard-fit, custom-fit and no brace conditions for the AKP cohort, but the braced conditions would have no influence on asymptomatic couplings. The secondary hypothesis was supported by AKP HAdd/Abd-KAdd/Abd and TRot-SRot coordination and KRot-AInv/Eve coordination variability differences across brace conditions. As coordination differences were additionally identified in the asymptomatic group, the secondary hypothesis was also partially supported.
4.1. Influence of
AKP on Coordination and Variability During Running
The AKP cohort used different HRot-KRot and
KRot-AInv/Eve strategies
than the asymptomatic cohort to complete the running task, spending
significantly less time in knee-dominant movement patterns during stance (Figure
1). The weight acceptance and loading
phases (early-and mid-stance) were achieved with a greater dominance of knee
angular motion (internal rotation) for the asymptomatic cohort when coupled
with hip external rotation and ankle inversion. The findings are consistent
with Wilson and Davis [9], who reported greater knee external rotation across
many activities, including running, for subjects with PFPS. During mid- and
late-stance, AKP participants typically employed knee external rotation
couplings, whereas the asymptomatic cohort transitioned through knee internal
rotation to external rotation at toe-off. External knee rotation has been found
to contribute to heightened patellofemoral joint contact pressure [26] and therefore appears a likely mechanism of AKP. However, further study is
required to determine whether the AKP coupling strategy is causative or a
mechanism for pain avoidance.
With reduced time spent in
knee-dominant couplings, the AKP cohort spent significantly longer than their
asymptomatic counterparts in anti-phase ankle-dominant couplings for KRot-AInv/Eve (external
rotation/eversion). The current study findings were supportive of previous
associations between PFPS runners and asynchrony (anti-phase motion) in
coupling outcomes [27], however, significantly greater anti-phase
couplings were also found for asymptomatic participants. Therefore, the
pathomechanic nature of anti-phase motion as suggested by Dierks, et al. [27] was not supported by the current
research findings. In addition to the potentially heightened importance of
joint dominancy over motion type (in-/anti-phase) for AKP development, the
findings of significance for inter-joint rather than inter-segment coupling are
indicative of the important contribution of multiple segments to the altered
change in control of movement with pain.
The appraisal of coordination
variability between asymptomatic and AKP cohorts revealed no significant
differences for the selected couplings across the stance phase. It is possible
that the pain levels of the AKP participants may not have been sufficient to
identify coordination variability differences at the set level of significance,
as was anticipated in accordance with the dynamical systems theory [14].
4.2. Influence of
Knee Bracing on Coordination and Variability
Knee bracing aims to provide external
support to impaired internal structures. As such, the role of the knee brace in
effectively assisting AKP moderation was anticipated to be evidenced through
altered coupling mechanics within the AKP cohort, with knee bracing having
little influence on the asymptomatic cohort couplings. Pain was found to be a
modifying factor in how individuals respond to knee bracing during running,
with standard- and custom-fit braces having a greater influence on couplings
for the asymptomatic cohort in comparison with the AKP participants. The AKP cohort used significantly different HAdd/Abd-KAdd/Abd and
TRot-SRot couplings
between conditions, although no paired differences were identified for TRot-SRot. For
the knee orthoses to be fully effective, differences between braced and no
brace conditions were expected for the AKP cohort. Post-hoc testing revealed HAdd/Abd-KAdd/Abd differences to exist between the standard- and custom-fit braces, with no
difference between the braced and no brace conditions. Subsequently,
coordination and coordination variability analyses of standard- and custom-fit
knee bracing provided little support for the ability of current knee braces to
effectively contribute to transitioning AKP participants to healthy coordinative
motion patterns. In addition to pain typically increasing, lower-limb
kinematics may be altered with increased running time [27]; it is possible that knee bracing
functionality may become more prominent during the study of prolonged running.
Asymptomatic individuals were found to
run with altered coupling mechanics within the braced condition in comparison
with the no brace condition for KRot-AInv/Eve, TRot-SRot and SRot-FInv/Eve.
As highlighted by Bellemans [28], even subtle changes to the well-designed
patellofemoral mechanism are anticipated to have important biomechanical
implications, subsequently, the findings are suggestive of the potentially
detrimental mechanical impact of wearing either the standard- or custom-fit
brace as a preventative measure. No paired statistical coordination variability
differences were found for couplings within either the asymptomatic or AKP
groups. As no coordination variability differences were found between the
groups in the no brace condition, the finding of no paired within-group bracing
differences is favorable for the use of standard- and custom-fit knee braces.
Although the braces aim to provide external support to the knee joint,
inter-joint and inter-segment coordination variability was found not to be
compromised.
5. Conclusion
When running with AKP, participants
have been shown to alter their hip-knee and knee-ankle kinematic couplings
compared to asymptomatic cohorts. The use of knee bracing alone may not be
sufficient to influence coordination patterns in attempt to transition AKP
lower-limb movement patterns to that of asymptomatic individuals. The results
suggest the mechanisms for knee pain extend beyond the knee joint and
therefore, consideration of proximal and distal lower-limb segments may be most
effective for injury prevention strategies.
Figures 1(a,b): Inter-joint
coupling angles across stance and coordination frequencies of asymptomatic and
AKP cohorts with no bracing; *P < 0.05.
Figures 2(a-e): Inter-joint/inter-segment
coupling angles and coordination frequencies of standard-fit, custom-fit and no
brace conditions within asymptomatic and AKP groups; *P < 0.05.
Figure 3: Coupling angle variability
for AKP group KRot-AInv/Eve across
the stance phase for standard-fit, custom-fit and no brace conditions; the shaded
region indicates statistical significance from SPM1d analyses (P < 0.05).
Coupling |
Coupling Planes |
Abbreviation |
Supporting Literature |
Hip-knee |
Sagittal-sagittal |
HFlex/Ext-KFlex/Ext |
[13,17] |
Frontal-frontal |
HAdd/Abd-KAdd/Abd |
[4,20] |
|
Transverse-transverse |
HRot-KRot |
[8,9] |
|
Knee-ankle |
Sagittal-sagittal |
KFlex/Ext-ADorsi/Plantar |
[21] |
Transverse-frontal |
KRot-AInv/Eve |
[21] |
|
Thigh-shank |
Transverse-transverse |
TRot-SRot |
[22] |
Shank-foot |
Transverse-frontal |
SRot-FInv/Eve |
[12] |
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