LATERAL INSTABILITY OF THE KNEE JOINT AND DISORDER OF THE ANKLE JOINT EXTENSION DISORDER IN MEN
Tomasz Tittinger1, Rafał Słoniak1, 2, Damian Szczepański3, , Tadeusz Szymon Gaździk4, Małgorzata Kulesa-Mrowiecka4, Łukasz Kikowski5
1REHABILITATION CENTRE, RZESZOW, POLAND
2THE HOLY FAMILY SPECIALIST HOSPITAL NTM, RUDNA MALA, POLAND
3 RZESZÓW UNIVERSITY OF TECHNOLOGY, CHAIR OF COMPUTER SCIENCE AND AUTOMATION, RZESZOW, POLAND
4JAGIELLONIAN UNIVERSITY, INSTITUTE OF PHYSIOTHERAPY, KRAKOW, POLAND
5Center for Prevention and Rehabilitation CREATOR, LODZ, POLAND
Introducion: The flexion of the knee joints in the movement of the squat may be accompanied by physiological varus deformity that increases smoothly with the lowering of the center of gravity, followed by a return to the starting position. Observing the disturbances of the physiological movement of the knee joints in the frontal plane, the authors correlated them with the mobility of the ankles in the sagittal plane.
The aim: To show the relationship of knee joint motion disorders in the frontal plane with the movement of the ankle joints in the sagittal plane in the movement of the squat. The authors asked themselves about the number of subjects with the physiological mobility of both joints in the given planes and in what part of the subjects there are disorders and whether they relate to the ipsi or the contralateral part of the body. There was also the question of whether and in which group there are deviations not meeting the above criteria.
Materials and methods: 20 healthy right-handed men aged 25-35 were examined with physiological mobility of lower limb joints, confirmed in a physiotherapeutic study. Exclusion criteria included: polyarticular laxity, systemic diseases, rheumatoid arthritis, osteoarthritis. The subjects performed a three-time squat after putting in the Biomech measuring system inertial sensors on the lower limbs and the pelvis. Assessment was related to the movement of the knee joint in the frontal plane with the movement of the ankle joint in the sagittal plane.
Results: Alternating deformity with right knee valgus occurred in 16 people in the right knee joint (80% of subjects) and in 6 men in the left knee joint (30% of subjects). Three subjects (15%) had a degenerative disorder in both knee joints. The others presented physiological mobility or single (not correlating) disturbances in the mobility of selected joints.
Conclusions: The tests confirmed that the ankle joint is functionally connected to the dysfunctional knee joint on the opposite side, despite various surfaces of mutual movement. Dysfunction of the knee joint is about 10 ° reduction of varus deformity during squat during maximum flexion of the knee joint and again varus deformation when lifting the center of gravity, which ends in distortion until the starting position. These deflections are accompanied by a decrease in the opposite ankle extension at the time of knee valgus deformity in the maximum flexion. The above dysfunctions occurred in 100% instability of the non-dominant knee joint, and on the dominant side in 63%.
Key words: lateral instability, knee, ankle, MVN Biomech
Wstęp: Zgięciu stawów kolanowych w ruchu przysiadu może towarzyszyć fizjologiczne szpotawienie narastające płynnie wraz z obniżaniem środka ciężkości, po którym następuje powrót do pozycji wyjściowej. Obserwując zaburzenia fizjologicznego ruchu stawów kolanowych w płaszczyźnie czołowej, autorzy skorelowali je z ruchomością stawów skokowych w płaszczyźnie strzałkowej.
Cel pracy: Wykazanie związku zaburzeń ruchomości stawów kolanowych w płaszczyźnie czołowej z ruchem stawów skokowych w płaszczyźnie strzałkowej w ruchu przysiadu. Autorzy zadali sobie pytania o ilość badanych z fizjologiczną ruchomością obu stawów w podanych płaszczyznach oraz w jakiej części badanych występują zaburzenia i czy dotyczą one ipsi-, czy kontrlateralnej części ciała. Pojawiło się również pytanie czy i w jakiej grupie występują odchylenia nie spełniające powyższych kryteriów.
Materiał i metody: Zbadano 20 zdrowych, praworęcznych mężczyzn w wieku 25 – 35 lat z fizjologiczną ruchomością stawów kończyn dolnych, potwierdzoną w badaniu fizjoterapeutycznym. Kryteria wyłączenia obejmowały: wiotkość wielostawową, choroby układowe, RZS, chorobę zwyrodnieniową stawów. Badani wykonali trzykrotny przysiad po założeniu czujników inercyjnych MVN Biomech na kończyny dolne i miednicę. Ocenie podlegały powiązania ruchu stawu kolanowego w płaszczyźnie czołowej z ruchem stawu skokowego w płaszczyźnie strzałkowej.
Wyniki: Naprzemienne szpotawienie z koślawieniem prawego stawu kolanowego wystąpiło u 16 osób w prawym stawie kolanowym (80% badanych), a u 6 mężczyzn w lewym stawie kolanowym (30% badanych). 3 badanych (15%) miało zaburzenie szpotawienia w obu stawach kolanowych. Pozostali prezentowali ruchomość fizjologiczną lub pojedyncze (nie korelujące ze sobą) zaburzenia ruchomości wybranych stawów.
Wnioski: Badania potwierdziły, że staw skokowy związany jest funkcjonalnie z dysfunkcyjnym stawem kolanowym po przeciwnej stronie, mimo różnych płaszczyzn wzajemnego ruchu. Dysfunkcja stawu kolanowego polega na około 10° zmniejszeniu szpotawienia podczas przysiadu podczas maksymalnego zgięcia stawu kolanowego i ponownym szpotawieniu podczas podnoszenia środka ciężkości, które kończy się koślawieniem do momentu uzyskania pozycji wyjściowej. Wychyleniom tym towarzyszy zmniejszenie wyprostu przeciwnego stawu skokowego w momencie koślawienia stawu kolanowego w maksymalnym jego zgięciu. Powyższe dysfunkcje wystąpiły w 100% niestabilności niedominującego stawu kolanowego, a po stronie dominującej w 63%.
Słowa kluczowe: niestabilność boczna, staw kolanowy, staw skokowy, MVN Biomech
Wiad Lek 2019, 72, 2, 250-254
The aim of this study was seizing non-physiological mobility within the knee joint in the frontal plane and an attempt to find the relationship of the dysfunction with the ankle joint.
Instability of the knee joint in the frontal plane enforces a compensatory disorder of the maximal extension movement in the opposite ankle joint.
MATERIALS AND METHODS
20 healthy right-handed men aged from 25 to 35 with physiological mobility of joints of the lower limbs have been examined, without signs of instability in the physiotherapeutic examination. The exclusion criteria included: polyarticular laxity, systemic diseases, rheumatoid arthritis (RA), osteoarthritis. The subjects performed a threefold squat after placing MVN Biomech inertial sensors on the lower limbs and the pelvis.
Relationship between the movement of the knee joint in the frontal plane with the movement of the ankle joint in the sagittal plane was subject to assessment. Three electronic measuring devices. i.e. an accelerometer, a gyroscope and a magnetometer in one case constitute an inertial measure unit (IMU). The current orientation of the IMU is calculated based on the temporary indication of the accelerometer and gyroscope. The magnetometer is used to become independent of the rotation of the IMU with respect to the axis of rotation parallel to the gravity vector. Additionally, as a result of double counting of the acceleration signa value in time, the displacement value in relation to each axis of the coordinate system is calculated. The sensors were placed on the so-called segments, i.e. the tendons and bellies of the extensor muscles of the ankle joint, the belly of the quadriceps femoris muscles and the sacrum, using special Velcro bands. At the intersection points of the segments (joints), a three-dimensional motion reading the current mobility of a particular joint was determined, providing the information about the range of motion (ROM) as well. In addition, knee and ankle joint stability tests were carried out, which did not detect hypermobility in the subjects.
The analysis of collected data has confirmed the correlation of the time of occurrence of the knee joint motion disorders in the frontal plane with the sagittal plane of the opposite ankle joint. The graphical variants of mutual dependencies between the knee joint and the opposite ankle joint are presented below.
Variant A. Negative values in the graph for the left knee joint confirm bendiness of this joint which – while lowering the centre of gravity – moves laterally (physiology) and – while raising the centre of gravity – returns to the starting position. The maximum flexion of the knee joint is accompanied by a smooth transition from the extension to bending of the opposite ankle joint. The described, normal movement has occurred in 2 people between the right knee joint and the left ankle joint (10% of the subjects) and in 4 people with the dependence of the left knee and right ankle joint (20% of the subjects).
Variant B. Flexion of the ankle joint correlates with distortion of the opposite knee joint. Negative, growing values on the knee joint chart confirm bendiness whereas decreasing numbers are evidence of the distortion. The knee joint of the examined person moves laterally (physiology) while lowering the centre of gravity to perform adduction (pathology) at the moment of maximal flexion and repeats the movement while raising the centre of gravity. Characteristically, the medial movement is accompanied by a disturbance of the maximal extension of the ankle joint as if the ankle joint retracted to flexion, which may indicate its instability. Comparing the right knee joint with the opposite ankle joint, 10 subjects (50%) have presented the described disorder and the relationship between the left knee joint with the right ankle joint affected 6 people (30% of the subjects).
Variant C. The left knee joint is marked with significant over 10° distortion (pathology), which is not accompanied by a considerable decrease in the opposite ankle extension at the peak of the movement (physiology). In the knee joint there is no characteristic double refraction of the abduction movement characteristic of variant B (which may force the ankle to deflect in the maximum extension range). This dependence has occurred only between the left knee joint and the right ankle joint in 30% of the subjects (6 people).
Variant D. The knee joint is subject to 5° bendiness and distortion occurs only in the rest position. Abnormal change in the maximum extension of the ankle joint for flexion does not disturb, in this variant of movement of the knee joint in the frontal plane. This has applied to 4 people (20% of the subjects) – 2 subjects with the right knee joint and left ankle joint and the same number with the left knee joint with the opposite ankle joint.
Variant E. Bendiness of the right knee joint changes to adduction, which is not accompanied by reduction of the opposite ankle extension in the maximum range of motion (physiology). Abnormal movement of the knee joint in the frontal plane did not cause disturbances of the opposite ankle joint extension. This variant has occurred only between the right knee joint and the left ankle joint in 6 people (30% of the subjects).
The knee joint is subject to significant, over 10° distortion (pathology), accompanied by a decrease in the opposite ankle joint extension in the maximum range of motion (pathology). Despite the lack of bendiness change to distortion in the knee joint characteristic of variant B, there is ankle joint flexion on the opposite side and this has concerned only 2 men (10% of the subjects) between the left knee joint and the right ankle joint.
In the majority of men, bendiness change to distortion of the knee joint was reported while lowering of the centre of gravity, followed by another bendiness ended in distortion after reaching the initial position. This phenomenon has occurred in 16 people in the right knee joint (80% of the subjects) and in 6 men in the left knee joint (30% of the subjects). Three subjects (15%) had a bendiness disorder in both knee joints. Correlation of the right knee joint disorders in the frontal plane with the opposite ankle joint in the sagittal plane has occurred in 10 people (50% of the subjects). Two subjects (10%) have had physiological bendiness of the right knee joint with a smooth transition from flexion to the opposite extension of the ankle joint – variant B physiology. In 2 men (10% of the subjects) there has been a disorder in the sagittal plane of the mobility of the ankle joint at the physiological bendiness of the knee joint – variant D.
In the system of the left knee joint and the right ankle joint in 6 subjects (30%), there has been a double change in mobility in the knee joint in the frontal plane and all have met the criteria of variant A (pathology). In 4 people (20% of the subjects) there has been a variant B physiology, and in 6 (30%) variant C, i.e. medial instability of the knee joint that was not accompanied by disorders of the ankle extension. In 2 men (10% of the subjects) there has been a disorder in the sagittal plane of the ankle joint mobility at the physiological knee joint abduction – variant D. The same number has been accompanied by medial instability of the knee joint with an abnormal extension of the opposite ankle joint (2 people – 10% of the subjects).
Isolated lateral instability of the knee joint constitutes a rare phenomenon because it occurs most frequently with instability in the sagittal plane . Lateral stability of the knee, apart from the ligaments and articular capsule, is secondarily influenced by the ischiocrural muscles and tensor fascia lata . In addition to ligament stabilization, other important structures are responsible for active stabilization, such as: hip belt, long and short heads of the biceps femoris, lateral tendon of the gastrocnemius muscle . The dynamic stability of the knee joint can be influenced by the appearance of metabolic fatigue during sports activity, which may increase the risk of knee injury . Dynamic control of knee joint work depends primarily on the eccentric ability to suppress overloads in the muscles of the lower limb and especially the quadriceps femoris . The fatigue of the quadriceps femoris increases the mobility of the dorsal flexion of the foot during landing after the jump. The ankle joint shows increased compensations during landing in the event of exercise fatigue in the quadriceps femoris . Functional training and strengthening the quadriceps femoris muscles affects reduction of bendiness of the lower limbs in the knee joints during the landing test from height .
The function of the ankle joint depends on the function of the knee joint on the opposite side. The ankle joint is functionally connected to the dysfunctional knee joint on the opposite side despite different surfaces of mutual movement. Dysfunction of the knee joint consists in about 10° reduction of bendiness during the squat at the maximum flexion of the knee joint and another bendiness while raising the centre of gravity, which ends in distortion until the initial position is reached. These deflections are accompanied by a decrease in the opposite ankle extension at the time of the knee joint distortion deformity in its the maximum flexion.
The above-mentioned dysfunctions have occurred in 100% of instability of the non-dominant knee joint and on the dominant side in 63%.
Therefore, knee joint disorders can occur in the absence of an opposite ankle impairment in 30% of the subjects (on the dominating side), where the amplitude of bendiness changes was about 5° in all subjects.
In 30% of the respondents, there has been an ankle disorder without characteristic bendiness deformity of the knee joint on the opposite side.
1. Baker CL Jr., Norwood LA, Hughston JC. Acute combined posterior cruciate and posterolateral instability of the knee. Am J Sports Med 1984;12:204-208.
2. Kakarlapudi TK, Bickerstaff DR. Knee instability. West J Med. 2001;174(4):266-272.
3. James EW, LaPrade ChM, LaPrade RF. Anatomy and Biomechanics of the Lateral Side of the Knee and Surgical Implications. Sports Med Arthrosc Rev 2015;23:2-9
4. Ortiz A. Fatigue Effects on Knee Joint Stability During Two Jump Tasks in Women. J Strength Condition Res. 2010;04(01)
5. Coventry E, O’Connor KM, Hart BA, Earl JE, Ebersole KT. The effect of lower extremity fatigue on shock attenuation during single-leg landing. Clin Biomech. 2006;21:1090-1097.
6. Orishimo KF, Kremenic IJ. Effect of fatigue on single-leg hop landing biomechanics. J Appl Biomech. 2006;22 (4):245-54.
7. Noyes FR, Barber-Westin S, Flekenstein CM. Difference in Lower Limb Control by Gender and Effect of Neuromuscular Training in Female Athletes. Am J Sports Med. 2005;33(2):197-207.
Conflict of interest:
There is no conflict of interest
ul. Miłocińska 95/1
Fig. 1. Variant A. 3 squats. Normal movement of the knee joint in the frontal plane and ankle joint in the sagittal plane.
Fig 2. Variant B. 3 squats. Double abnormal movement of the knee joint in the frontal plane, with accompanying ankle joint disorder in the sagittal plane.
Fig 3. Variant C. 3 squats. The knee joint in the frontal plane, ankle joint in the sagittal joint. Medial instability of the knee joint (distortion), normal movement of the ankle joint.
Fig 4. Variant D. 3 squats. Normal movement of the knee joint despite the disorder of the maximum extension of the opposite ankle joint.
Fig 5. Variant E. 3 squats. Normal movement of the ankle joint despite the change of bandiness for distortion of the knee joint of small amplitude.
Fig 6. Variant F. 3 squats. Abnormal distortion of the knee joint with ankle joint extension disorder. Medial instability of the knee joint is accompanied by the ankle joint disorder characteristic of variant B.