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what is the relationship of the foot to the knee?

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Relationship between human foot function and medial knee joint loading in people with medial compartment knee osteoarthritis

  • Hylton B Menz2,
  • Adam D Morrowtwo,
  • John R Bartlett3,
  • Julian A Feller2 &
  • Neil R Bergman3

Journal of Pes and Talocrural joint Research book 6, Article number:33 (2013) Cite this commodity

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Abstract

Groundwork

Dynamic joint loading, particularly the external human knee adduction moment (KAM), is an important surrogate mensurate for the medio-lateral distribution of strength across the knee joint in people with articulatio genus osteoarthritis (OA). Foot movement may alter the load on the medial tibiofemoral joint and hence affect the KAM. Therefore, this written report aimed to investigate the relationship between tibia, rearfoot and forefoot move in the frontal and transverse planes and the KAM in people with medial compartment genu OA.

Method

Move of the knee, tibia, rearfoot and forefoot and knee moments were evaluated in 32 patients with clinically and radiographically-confirmed OA, predominantly in the medial compartment. Pearson'due south correlation coefficient was used to investigate the association betwixt meridian values of tibia, rearfoot and forefoot motion in the frontal and transverse planes and 1st peak KAM, iind peak KAM, and the articulatio genus adduction angular impulse (KAAI).

Results

Lateral tilt of the tibia was significantly associated with increased 1st peak KAM (r = 0.threescore, p < 0.001), 2nd peak KAM (r = 0.67, p = 0.001) and KAAI (r = 0.82, p = 0.001). Increased peak rearfoot eversion was significantly correlated with decreased iind tiptop KAM (r = 0.59, p < 0.001) and KAAI (r = 0.fifty, p = 0.004). Decreased rearfoot internal rotation was significantly associated with increased 2nd acme KAM (r = −0.44, p = 0.01) and KAAI (r = −0.38, p = 0.02), while decreased rearfoot internal rotation relative to the tibia was significantly associated with increased 2nd tiptop KAM (r = 0.43, p = 0.01). Significant negative correlations were found between peak forefoot eversion relative to the rearfoot and twond peak KAM (r = −0.53, p = 0.002) and KAAI (r = −0.51, p = 0.003) and between top forefoot inversion and 2nd peak KAM (r = −0.54, p = 0.001) and KAAI (r = −0.48, p = 0.005).

Decision

Increased rearfoot eversion, rearfoot internal rotation and forefoot inversion are associated with reduced knee adduction moments during the opinion phase of gait, suggesting that medial knee joint loading is reduced in people with OA who walk with greater foot pronation. These findings have implications for the blueprint of load-modifying interventions in people with knee OA.

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Background

Knee osteoarthritis (OA) is a chronic debilitating status, affecting a substantial number of older people worldwide [i, 2]. People with articulatio genus OA suffer from pain and difficulties in performing activities of daily living. OA in the medial compartment of the human knee is highly prevalent and has been attributed to the increased load transmitted across the medial compartment of the knee joint [iii]. Although several factors have been associated with the incidence and progression of OA, particularly medial compartment knee OA, the aetiology of articulatio genus OA is not fully understood. Biomechanical factors associated with joint loading take been the focus of recent studies equally an of import element in the pathogenesis of genu OA.

Dynamic joint loading, especially the external knee adduction moment (KAM), has received attention equally an important surrogate mensurate of the medio-lateral distribution of force across the genu joint. Although the evidence for the contribution of KAM to the development of knee joint OA is inconsistent [iv], several studies accept shown increased KAM to be associated with articulatio genus OA severity and varus malalignment [5]. Consequently, several treatment strategies, including load modifying interventions, have been suggested to reduce the load on the medial compartment of the knee by altering the KAM [half-dozen–12].

The KAM is influenced by variation in lower limb alignment and motion during gait [13–17]. Varus limb alignment, which is commonly observed in people with medial compartment knee OA, has been shown to increment the incidence and progression of knee OA [18–twenty]. Recent studies have too reported that people with medial compartment knee OA have a relatively pronated foot posture [21–23] and demonstrate foot kinematic patterns that are indicative of a less mobile, everted foot type [24] compared to controls. Moreover, the degree of varus alignment may besides affect human foot motion during walking which may lead to a compensatory response to allow typical function of the pes during ambulation [24]. Footwear and orthotic interventions, therefore, have been studied every bit a method for altering medial knee loading past altering human foot motility [6–12].

The machinery past which footwear and orthotic interventions aim to reduce the human knee adduction moment is by pronating the pes through lateral inclination of the insole (thereby laterally shifting the centre of pressure level) [25]. However, it is unclear if variation in foot motion, peculiarly foot eversion, influences the KAM. In order to improve understand how knee joint loading is influenced by lower limb motion, this written report investigated the human relationship betwixt tibia, rearfoot and forefoot move in the frontal and transverse planes and KAM in people with medial compartment knee OA. Nosotros hypothesised that kinematic parameters indicative of greater foot pronation (internal tibial rotation, frontal plane rearfoot eversion and frontal plane forefoot inversion) would be associated with a reduction in medial articulatio genus articulation loading.

Methods

This project was function of a larger study that investigated gait (swing phase mechanics, specially minimum foot clearance), balance and falls take a chance in people before and later knee arthroplasty. A power calculation to determine the sample size, therefore, was based on minimum foot clearance parameters. Data from a previous study [26] which investigated the toe clearance of elderly fallers and non-fallers were used to determine the number of participants required. A sample size calculation indicated that for 80% power and a p value of 0.05 at to the lowest degree 25 participants were required. To mitigate the possible effect of subject driblet out for the surgical grouping, a total of 32 participants were considered to be sufficient. Xxx 2 participants (16 females, average historic period 65.8 ± vii.five twelvemonth, height 168.viii ± 9.v and trunk weight 85.ane ± 13.6kg) with diagnosed OA predominantly in the medial compartment of the knee, determined by radiographic assessment [24], participated in the study. Detail of the foot posture of the participants has previously been reported [21]. The severity of human knee OA was based on the loss of joint space determined by an orthopaedic surgeon from radiographic images [27] and was graded every bit follows: 1- less than a half of articulation space loss (mild), 2 - more than a one-half of joint space loss; bone on bone (moderate) and iii - os deformity/loss of bone (severe). Each compartment of the knee joint (medial compartment, lateral compartment and patellofemoral compartment) was graded and participants with predominantly medial compartment human knee OA (severity form two–3) were included in the study. Xvi participants had moderate severity of OA (grade 2) and xvi participants had severe OA (form 3) based on radiographic assessment [27]. Participants were included if they were able to walk independently and were excluded if they had uncontrolled systemic disease and or a pre-existing neurological or other orthopaedic condition that afflicted their walking. Participants were recruited from the La Trobe University Medical Center, the Warringal Private Medical Centre and through advertisements in local newspapers. Ethics approval was obtained from the Faculty of Health Sciences Human Ethics Committee, La Trobe Academy. All participants were informed about the nature of the study and signed a consent grade prior to participation.

Procedure

Instrumentation

A three dimensional motion assay organization (Vicon MX, Vicon Motion System Ltd, Oxford, England) with 10 cameras (eight MX3 and 2 MX40) was used to capture and analyse motion of the lower leg with a sampling frequency of 100Hz. 2 forcefulness plates (Kistler, type 9865B, Winterthur, Switzerland and AMTI, Watertown, MA, The states) (1000Hz) were used to capture footing reaction forces and identify gait cycle events. The marking trajectories and force platform information were captured synchronously using the Vicon Nexus software package. The force plate data were and so re-sampled at 100Hz for the calculation of knee joint moments.

Kinematic evaluation

Participants were required to attend a single testing session at the gait laboratory at La Trobe Academy. Lower leg and foot move of the symptomatic leg (or the most symptomatic leg in a example of bilateral interest) was assessed. To assess the three dimensional motion of the lower limb including, knee, tibia, rearfoot and forefoot and articulatio genus moments in the frontal plane, retro-reflective markers were attached on anatomical landmarks over the lower legs in accord with the Oxford Pes Model (OFM) marker ready and Plug In Gait (PIG) [28] equally described by Stebbins et al. [29]. Retro-reflective markers were and then placed over the anatomical land marks on the pelvis, thigh, tibia, rearfoot and forefoot as described in details in Levinger et al. [24]. The OFM modelled the tibia, rearfoot and forefoot equally rigid segments. The tibial segment was comprised of markers placed on the medial malleolus, the lateral malleolus, the anterior aspect of the tibial crest, the tibial tuberosity and the caput of the fibula. The rearfoot segment was defined by placing markers on the sustentaculum tali, the lateral calcaneus, the heel (distal part of the calcaneus), the posterior proximal calcaneus and a peg marker was placed on the posterior calcaneus between the heel and proximal calcaneus markers. The forefoot segment was divers by placing markers on the most distal, medial aspect of the first metatarsal shaft, the most proximal and distal lateral aspects of the fifth metatarsal shaft, and midway betwixt the second and 3rd metatarsal heads.

Prior to kinematic evaluation of the lower leg motility, a relaxed continuing calibration trial was captured with articulatio genus alignment devices (KAD, Motion Lab Systems Inc. LA, United states). Several markers, used only in the static trials (medial malleoli, proximal heel, and first metatarsal), were removed prior to the dynamic trials as described in Stebbins et al. [29]. The locations of the joints centre were calculated from Grunter [28]. Moreover, the location of the knee joint centre, calculated from Grunter, was further used in the OFM for the tibia segment definition.

Participants were asked to walk at a comfortable walking footstep forth a 12m walkway and five successful trials were collected for each leg. A successful trial was defined when the participant's foot landed on the centre of the forcefulness plate without any interference to their gait. For each trial, gait events were detected using vertical ground reaction force data to make up one's mind initial foot contact and toe off. Multiple trials were practiced until participants were comfy and walking with consequent velocity. The peak values of interest (maximum value during the stance phase) of each trial were extracted separately; the average of the 5 trials was so used in the analysis. All gait variables of interest generated past the model were normalised to the gait cycle and timing of peak angular variables were then expressed equally a percentage of the gait wheel.

The magnitude of elevation angular motion of the tibia, rearfoot relative to the global coordinate system (laboratory), rearfoot relative to the tibia and forefoot relative to the rearfoot in the frontal and transverse planes during the gait wheel were extracted including the following angles: (i) tibia lateral tilt and internal/external rotations (two) summit rearfoot eversion/inversion and internal/external rotation relative to the tibia; (three) rearfoot eversion/inversion and internal/external rotation relative to the global reference organisation (laboratory); (iv) peak forefoot abduction/adduction; and eversion/inversion. Knee frontal airplane angular movement (knee varus) during initial contact and during stance (height knee varus) and external KAM (normalised to % of trunk weight*height) including ist peak and 2nd peak were likewise extracted. Knee adduction athwart impulse (KAAI - the integral of the frontal aeroplane knee joint moment over the stance phase of the gait wheel) [30] was also calculated. Figure 1 depicts the influence of knee alignment on the KAM, and Figure ii depicts the three kinetic variables extracted from this information (anest peak KAM, 2nd peak KAM and KAAI).

Effigy 1
figure 1

The articulatio genus adduction moment (KAM) increases when walking with greater varus alignment of the knee (shown on the right) as the perpendicular distance of the ground reaction force vector from the articulatio genus articulation centre is greater, resulting in a longer moment arm.

Full size paradigm

Figure 2
figure 2

Frontal plane external KAMs: 1 st peak KAM, 2 nd peak KAM and knee adduction angular impulse (KAAI), which represents the area under the curve.

Full size prototype

Articulatio genus pain, part and stiffness

Clinical severity of OA including physical role, pain and stiffness were assessed using the Western Ontario and McMaster Academy Osteoarthritis Alphabetize (WOMAC) [31]. This index, using 10mm visual analogue scale, assesses the severity of the knee hurting during 5 daily activities (range 0 – 500), stiffness (range 0 – 200), and the severity of impairment of lower-extremity office during 17 activities (0 – 1700). A score of zippo represents no pain or difficulty with concrete part and higher scores represent worse functional wellness. All three subcategories are summed to give a global WOMAC score (range 0 – 2400).

Statistical analysis

Pearson'south correlation coefficient was used to investigate the relationship betwixt acme KAMs (1st peak KAM and 2nd superlative KAM), KAAI and the following parameters: peak values of tibia, rearfoot (both relative to the laboratory and relative to the tibia) and forefoot motility in the frontal and transverse planes.

Results

Hateful ± standard divergence external KAMs (% bodyweight * acme) were equally follows: 1st meridian KAM = iii.3 ± 1.6, iind acme KAM = ii.eight ± 1.1 and KAAI = 1.26 ± 0.5. Correlations between foot motility and KAM-related variables are shown in Tabular array i. Angular motion of the tibia, rearfoot and forefoot in the frontal and transverse planes are presented in Figures 3 and 4. The knee OA group reported balmy pain of 171.8 ± 99.9, function 502.5 ± 330.ix and stiffness 83.7 ± 49.eight with WOMAC total score of 758.1 ± 447.1.

Effigy 3
figure 3

Hateful movement of the tibia, rearfoot and forefoot in the frontal plane expressed relative to the percentage of the gait cycle.

Full size prototype

Effigy 4
figure 4

Hateful motion of the tibia, rearfoot and forefoot in the transverse plane expressed relative to the per centum of the gait bicycle.

Full size image

Table i Correlations between peak rearfoot and forefoot motion in the frontal aeroplane and tiptop articulatio genus adduction moments (KAM) and human knee adduction angular impulse (KAAI)

Total size table

Greater lateral tilt of the tibia was significantly correlated with increased KAMs and KAAI (r = 0.threescore to 0.82, p = 0.001). No correlations were found betwixt tibial rotation and KAMs (Tabular array 1). Meaning positive correlations were constitute between summit rearfoot eversion relative to the laboratory and 2nd pinnacle KAM (r = 0.59, p < 0.001) and KAAI (r = 0.50, p = 0.004), indicating decreased adduction moments with greater rearfoot eversion. Reduced rearfoot internal rotation relative to the laboratory was significantly correlated with greater twond peak KAM (r = −0.44, p = 0.01) and KAAI (r = −0.38, p = 0.02). Similarly, increased rearfoot external rotation relative to the laboratory was significantly correlated with greater 2nd meridian KAM (r = −0.54, p = 0.001) and KAAI (r = −0.48, p = 0.005). No significant correlations were plant betwixt either acme rearfoot eversion or inversion relative to the tibia and any of the KAMs. Reduced rearfoot internal rotation relative to the tibia was significantly correlated with increased twond peak KAM (r = 0.43, p = 0.01).

Significant negative correlations were plant betwixt peak forefoot eversion and 2nd peak KAM (r −0.53, p = 0.002) and between summit forefoot inversion and 2nd peak KAM (r = −0.54, p = 0.001). Similar correlations were also establish between forefoot peak eversion and inversion and KAAI. The forefoot is by and large inverted during the stance stage equally information technology is afflicted by rearfoot eversion [24]. Therefore, a negative correlation indicates an association between increased forefoot inversion and reduced knee impulse and KAMs.

Discussion

Load-modifying interventions accept been proposed as a strategy to reduce medial compartment genu loading (by reducing the external KAM) in people with knee OA, however equivocal findings have been reported regarding their effectiveness [ten, 25, 32, 33]. These strategies rely on altering knee articulation loading by modifying movement of the foot, suggesting that by influencing foot motion, the moment arm of the ground reaction force that passes medially to the knee joint heart is reduced (Figure ane). Understanding the relationship between lower leg and foot motion and KAMs tin can therefore provide useful information to help optimise intervention strategies. In the present report, we found several associations between human foot and tibia motion and external adduction moments at the knee which may influence the design of load-altering interventions for knee OA.

Human knee varus is frequently observed in people with medial compartment knee OA, with evidence suggesting that knee varus alignment increases the incidence and progression of OA [18–twenty]. We found significant correlations between lateral tibial tilt and KAMs and KAAI, indicating that greater tibial tilt increases the load on the medial compartment of the human knee joint. These findings were expected, as greater tibial lateral tilt would increase the perpendicular distance of the footing reaction force vector from the articulatio genus articulation heart, resulting in a greater moment arm and adduction moment (Effigy 1). No correlation, yet, was institute in the transverse plane. Interestingly, an clan between OA progression and torsional deformity in the tibia has previously been reported, every bit a decrease in tibial external rotation was accompanied by an increase in disease severity [34]. We have previously reported that people with knee OA have greater tibial internal rotation compared to aged-matched controls [35], and a reduction in tibial internal rotation was observed in patients who underwent realignment of the knee following knee replacement surgery [35]. Furthermore, internal torsion and varus deformity take been associated with increased loads on the medial compartment of the human knee [36]. The lack of correlation in the present study betwixt tibia rotation and KAMs may be related to a possible restriction in tibial motion as patients may exist "pushed" to the end range of motion due to years of walking in the same pattern. Notwithstanding, due to the cantankerous-sectional design of these studies, we are unable to infer the management of causation between tibial rotation and the load on the medial compartment of the knee.

A pregnant association between rearfoot eversion relative to the laboratory and KAMs and KAAI was establish, indicating that increased foot pronation is associated with reduced medial knee articulation loading. In our previous work, the same knee joint OA group exhibited a relatively pronated foot type compared to an age-matched control group [21]. Greater internal rotation and reduced external rotation of the rearfoot relative to the lab were besides associated with reduced 2nd superlative KAM and KAAI. Motility of the rearfoot in the frontal aeroplane is coupled to internal rotation of the rearfoot, equally previously reported in apartment biconvex-feet [37]. Consequently, greater rearfoot eversion and internal rotation were associated with reduction of the overall medial loading during the stance phase of gait. Unlike rearfoot motion relative to the tibia, rearfoot movement relative to the laboratory is an contained measure of absolute rearfoot motion which may therefore more closely represent the link between rearfoot motion and knee moments.

Pregnant correlations were too constitute between forefoot frontal plane motion and peak KAMs, indicating that increased forefoot inversion was related to reduced knee impulse and KAM during mid and late stance phase. Due to the coupling motility between the rearfoot and forefoot [38], inversion of the forefoot during stance phase is affected past the degree of rearfoot eversion, therefore the greater rearfoot eversion in the knee OA grouping would brand the forefoot relatively inverted. It is too possible that motion of the midfoot in the frontal airplane affects medial genu loading, however due to the absenteeism of a midfoot segment in the Oxford human foot model, we are unable to determine the contribution of midfoot motion to contradistinct medial articulatio genus loading. Kinematic foot models which allow for more detailed analysis of the midfoot may be of additional benefit to amend empathise foot function in people with medial compartment knee joint OA. Nevertheless, based on our current findings, the correlations establish between frontal airplane rearfoot and forefoot motion and summit KAMs suggest that those with greater peak rearfoot eversion and forefoot inversion exhibited reduced medial articulatio genus joint loading during the mid- to late opinion phase of gait.

Interestingly, the associations found between human foot kinematics and KAMs did non involve the anest peak KAM, which is nigh often targeted with load-altering interventions. In that location are a number of possible explanations for this. Firstly, there are differences in timing of when these peaks occur during gait. The onest peak KAM for the knee OA group occurred at early stance (average 19.1% gait bicycle) while meridian rearfoot eversion occurred at 30% of the gait cycle. Secondly, it is possible that the movement of the midfoot may be related to medial human knee loading, as midfoot motion can compensate for rearfoot movement. Further investigation, however, is required to ascertain this. Lastly, previous studies take suggested that there may be distinct subgroups of individuals based on timing patterns of rearfoot frontal plane motility [39]. Participants with an "early" rearfoot eversion pattern (ie. rapid eversion in the first x% gait wheel) may be more probable to exhibit changes in KAM associated with load-altering interventions, which may explain why these interventions are more effective in some subpopulations than others. It is also important to acknowledge that KAAI has been shown to exist a more sensitive mechanical joint loading parameter than top KAMs [twoscore]. Given that the KAAI takes into account both the magnitude and elapsing of knee joint medial loading, the correlation betwixt greater acme rearfoot eversion and forefoot inversion and reduced KAAI may indicate overall reduction of medial knee joint loading during stance.

Reports of the biomechanical effects of different load modifying interventions (orthotics and shoes) have been inconsistent [10, 25, 32, 33]. While some studies investigating lateral wedged insoles have reported a reduction in the KAMs [10, 11, 33, 41], others have reported an increment in KAM [25, 32, 33]. Different insole lengths take likewise shown unlike responses, with full length insoles existence more constructive at reducing KAM than heel wedges [10]. These findings support the proposition that there may be sub-groups that amend respond to lateral wedged insoles, and that variability in response to orthotic intervention may be evident in people with medial compartment knee OA [24]. Footwear-related interventions, such as variable stiffness shoes, have as well demonstrated a reduction in the KAM [vi, 12, 42] with evidence suggesting a reduction in the medial compartment in vivo contact forcefulness [12]. It may be possible that insole interventions which aim at modifying motion of the whole foot (rearfoot, midfoot and forefoot), such as shoes and full length insoles, may exist more constructive due to their effect on forefoot frontal aeroplane motion in addition to altering rearfoot motion. However, due to the potential high variability in response to load modifying interventions, appropriate individual screening of the lower limb may demand to exist undertaken to appraise the suitability of the intervention and to attain optimal clinical outcomes.

Conclusion

Associations between kinematic measures at the human foot and moments at the genu indicate that increased rearfoot eversion, rearfoot internal rotation and forefoot inversion are associated with reduced KAM and KAAI during the opinion stage of gait. These findings suggest that medial genu joint loading is reduced in people with OA who walk with greater foot pronation. Due to the loftier variability reported to load modifying interventions in people with medial compartment knee OA, individual screening of the lower limb may need to be performed to appraise suitability for these interventions and to achieve optimal clinical outcomes.

Abbreviations

OA:

Osteoarthritis

KAM:

Knee adduction moment

KAAI:

Knee adduction athwart impulse.

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Acknowledgements

This study was funded by the Clive and Vera Ramaciotti Foundation and the Arthritis Foundation of Australia. HBM is currently a National Health and Medical Research Council Senior Research Young man (ID: 1020925). PL is currently funded through the Australian Regime's Collaborative Research Networks programme.

Author data

Affiliations

  1. Institute of Sport, Exercise and Active Living, College of Sport and Exercise Science, Victoria University, Melbourne, Vic, 8001, Australia

    Pazit Levinger

  2. Lower Extremity and Gait Studies Program, Faculty of Wellness Sciences, La Trobe University, Melbourne, Vic, 3086, Australia

    Pazit Levinger, Hylton B Menz, Adam D Morrow & Julian A Feller

  3. Warringal Medical Centre, Melbourne, Vic, 3084, Australia

    John R Bartlett & Neil R Bergman

Corresponding author

Correspondence to Pazit Levinger.

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Competing interests

HBM is Editor-in-Chief of the Journal of Foot and Talocrural joint Research. It is journal policy that editors are removed from the peer review and editorial determination making processes for papers they accept co-authored.

Authors' contributions

PL: designed and managed the report, collected and analysed the data drafted the manuscript. HBM: participated in the study pattern and assisted in the statistical analysis and data interpretation, helped to draft the manuscript. ADM: assisted in data drove, data analysis. JF, JB and NB have assisted in patient recruitment, grading x-ray severity and drafting the manuscript. PL, HBM and JF obtained the funding. All authors have read and approved the final version.

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Levinger, P., Menz, H.B., Morrow, A.D. et al. Human relationship between foot function and medial knee joint articulation loading in people with medial compartment genu osteoarthritis. J Foot Ankle Res 6, 33 (2013). https://doi.org/10.1186/1757-1146-six-33

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  • DOI : https://doi.org/10.1186/1757-1146-vi-33

Keywords

  • Knee osteoarthritis
  • Foot motion
  • Knee adduction moment

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