The effects of functional knee bracing and taping of the tibio-femoral joint in athletes with an ACL

337 Pages·2017·31.15 MB·English

by  Christine Middleton

Division of Orthopaedic & Accident Surgery
(Centre for Sports Medicine)
University of Nottingham
The Effects Of Functional Knee Bracing And
Taping On The Tibio-Femoral Joint In Athletes
With An ACL-Deficient Knee
By
Abbas Rahimi
BSc MSc PT (Tehran University, Iran)
Thesis Submitted To The University Of Nottingham for the Degree of
Doctor of Philosophy
OCTOBER 2001
ABBREVIATIONS
CONTENTS
CO NTENTS ............................................................. ;. .......................................................
I
ABSTRACT ...................................................................................................................... iv
ABBREVIATIONS ........................................................................................................... v
ACKNOWLEDGEMENTS .............................................................................................. vi
DECLARATION ............................................................................................................ viii
LIST OF FIGURES .......................................................................................................... ix
LIST OF TABLES ............................................................................................................ xi
INTRODUCTION .................................................................................................-.-.-.-.-.-.-.-... 1
Organisation of the Thesis .................................................................. :. ............................. 5
CHAPTER ONE - KNEE JOINT ....................................... ~~ ......................................... 6
1.1. Anatomy of the Knee Joint ......................................................................................... 6
1.1.1. Cruciate Ligaments ............................................................................................... 7
1.1.2. Function and Kinematics of the ACL ................................................................... 9
CHAPTER TWO -LITERATURE REVIEW ............................................................ 15
2.1. Biomechanics of the Anterior Cruciate Ligament (ACL) ... :. .................................... 15
2.1.1. Demography of ACL Injury ............................................................................... 16
2.1.2. Mechanism of Injury .......................................................................................... 17
2.1.3. The Fate of ACL-Deficient Knee Subjects ........................................................ 18
2.2. Biomechanical Studies in ACL-Injured Knees ......................................................... 19
2.2.1. "In vitro (Cadaveric)" Studies ........................................................................... 19
2.2.2. "In vivo" Studies ................................................................................................. 21
2.3. Bracing ...................................................................................................................... 35
2.4. Functional Knee Bracing .......................................................................................... 38
2.5. Bracing of the ACL-Deficient Knee "A Review of the Literature" ......................... 40
2.4.1. Static Brace Studies ............................................................................................ 40
2.5.2. Dynamic Brace Studies ....................................................................................... 42
2.6. Kinetic Analysis Following FKBs on the ACL-Deficient Knee ~ ................... 57
r ..........
2.6.1 Quadriceps Avoidance Gait (QAG) Pattern in Detail ......................................... 63
2.7. Taping ....................................................................................................................... 70
2.7.1. Use of Taping in the Later Stages oflnjury Management ................................. 70
2.7.2. The Effects of Taping on the Tibio-Femoral Joint ...................... :. ..................... 71
2.8. Summary of the Literature Review ......................................................... 75
2.9. Translatory Kinematic Analysis of the ACL-Deficient Knee Joint - A Review of the
Literature ...................................... :'. .................................................................................. 79
2.9.1. Direct (Invasive) Methods .................................................................................. 79
2.9.2. Indirect (Non - Invasive) Methods ..................................................................... 80
2.10. Techniques to Reduce the Artefacts Caused by Surface Markers in Gait Analysis
Studies .............................................................................................................................. 82
2.111. Recommendations for This Study ......................................................................... 83
CHAPTER THREE -MATERIALS AND METHODS ............................................ 85
3.1. General Methods and Specifications ........................................................................ 85
3.2 Aims and Objectives of the Study ............................................................................. 85
3.3. Hypotheses to Be Tested ........................................................................................... 85
3.3.1. Detailed Hypotheses ........................................................................................... 86
ABBREVIATIONS
3.4. Recruitment of Subjects ............................................................................................ 86
3.4.1. ACL-Deficient Subjects .........................................................•........................... 86
3.4.2. Control Group .................................................. :. ................................................. 87
3.5. Clinical Description of the Patients ...................... ; ................................................... 87
3.5.1. Inclusion Criteria ................................................................................................ 87
3.5.2. Exclusion Criteria ............................................................................................... 87
3.6. Ethical Committee Approval .................................................................................... 88
3.7. Test Modes ................................................................................................................ 88
3.8. Outcome Measurements .................................................................. ~ ........................ 88
3.8.1. Primary Outcome Measures ............................................................................... 88
3.8.2. Secondary Outcome Measure ............................................................................. 92
3.9. Gait Analysis Equipment .......................................................................................... 93
3.9.1. CODA mpx30 Motion Analysis Unit. ................................................................ 94
3.9.2. Force Plate .......................................................................................................... 96
3.9.3. Telemetered Dynamic Electromyography System ..... :. ...................................... 96
3.9.4. Treadmill ............................................................................................................ 97
3.9.5. Functional Knee Brace ....................................................................................... 97
3.9.6. Taping ................................................................................................................. 98
3.10. Other Measurements ............................................................................................... 99
3.11. Recording of Dynamic EMG .................................................................................. 99
3.11.1. Electrode Placement ......................................................................................... 99
3.11.2. Skin Preparation ............................................................................................. 100
3.11.3. Muscles Tested .....................................................................: ......................... 100
3.11.4. Position of the Electrodes ............................................................................... 100
3.12. CODA's Marker Placement Set-up ........................... ~ .......................................... 100
3.13. Clustering Marker Placement Used in This Study ................................................ 101
3.14. Virtual Markers ..................................................................................................... 103
3.15. Procedure of Calculation of the Tibial Translation in This Study (Virtual Marker
Method) .............................. ~ ........................................................................................... 104
3.16. Final Procedure for Recording .............................................................................. 107
3.17. Data Processing ..................................................................................................... 109
3.18. Statistical Analysis Used in This Study ................................................................ 110
3.19. Power Calculation ................................................................................................. 111
3.20. Summ'ary of Methodology of the Research .................................................~ ........ 113
CHAPTER FOUR - PILOT STUDY ......................................................................... 121
4.1. Repeatability Test ............................................................................. ;. .................... 121
4.1.1. Aims ................................................................................................................. 122
4.1.2. Equipment ........................................................................................................ 122
4.1.3. Data Analysis ............... :: .................................................................................. 122
4.1.4. Results ............. :. ............................................................................................... 122
4.2. Pilot Study ......................................................................................... :. .................... 126
4.2.1. Aims .................................................................................................................. 126
4.2.2. Procedure .......................................................................................................... 126
4.2.3. Test Modes ....................................................................................................... 126
4.2.4. Equipment for Data Collection ......................................................................... 127
4.3. Patients' Screening-................................................................................................. 127
4.3.1. Subjects Characteristics ......................................... :. ......................................... 127
4.4. Results ..................................................................................................................... 129
4.5. Amendments to the Main Study ............................................................................. 130
4.6. Summary of the Pilot Study ................................................................ 131
ii
ABBREVIATIONS
CHAPTER FIVE -RESULTS .................................................................................... 133
5.1. Characteristics of the Study Sample ............................ : .......................................... 133
5.1.1. Control Subjects ............................................................................................... 133
5.1.2. ACL-Deficient Subjects ................................................................................... 133
5.2. Comparison of the Control Subjects and the Study Group ..................................... 137
5.3. Kinematic Data Analysis ........................................................................................ 137
5.3.1. Temporospatial Gait Parameters ...................................................................... 137
5.3.2. Range Of Motion (ROM) ................................................................................. 143
5.3.3. Kinematics -Joint Positions ............................................................................. 149
5.3.4. Knee Rotation ................................................................................................... 167
5.3.5. Anterior-Posterior (A-P) Tibial Translation ........................... ~ ......................... 172
5.4. Kinetic Data Analysis ............................................................................................. 177
5.4.1. Moments and Power ......................................................................................... 177
5.5. Ground Reaction Force Data Analysis ................................................................... 191
5.5.1. Vertical (Impact) Force .................................................................................... 192
5.5.2. Anterior-Posterior shear Force ......................................................................... 192
5.6. EMG Data Analysis ................................................................................................ 196
5.6.1. Gastrocnemius Muscle and Different Movement Surfaces .............................. 205
5.7. Summary of the Results .....................................................................2 11
CHAPTER SIX - DISCUSSION ................................................................................. 219
6.1. GENERAL DISCUSSION ..................................................................................... 219
6.1.1. Why Was This Study Necessary? .................................................................... 220
6.1.2. Strengths and Limitations of This Study .......................................................... 222
6.1.3. Marker Placement Set-up ................................................................................. 225
6.2. Results Interpretation .............................................................................................. 227
6.2.1. Kinematics ........................................................................................................ 227
6.2.2. Kinetics ............................................................................................................. 252
6.2.3. Force ................................................................................................................. 261
6.2.4. Electromyography (EMG) ................................................................................ 263
6.3. Summary of Discussion ......................................................................2 76
CHAPTER SEVEN - CONCLUSIONS .................................................................... 280
CHAPTER EIGHT ............ ~ ........ '. ..................................... :. ..................... ;. ....................... .
RECOMMENDATIONS FOR FUTURE RESEARCH .................................. ~ .. ~ ..... 285
REFERENCES ............................................................................................... :. ............ 287
Journals .................................................... : .............................................. :. ..................... 287
Books ............................................ ;. ............................................................................... 305
Conference Proceedings ................................................................................................ 307
Internet Communications ............................................................................................... 307
Theses .~ .......................................................................................................................... 308
APPENDICES ..................... ~ ........................................................................................ 309
Publications & Presentations ..... :. ..................................................... ;. ........................... 309
Ethical Committee Approval ......................................................................................... 310
Lysholm Score Form ..................................................................................................... 314
Consent Form ................................................................................................................. 316
Subject Information Sheet ............................................................................................. 317
Letter To GP ................................................................................ ;, ................................. 318
. A Summary of the Project in Lay Language ................................................................. 319
Glossary ...................................................................................................... ........................... 320
iii
ABSTRACT
ABSTRACT
By Abbas Rahimi, Supervised by Professor W Angus Wallace, Division of Orthopaedic and
Accident Surgery, School of Medical and Surgical Sciences, University of Nottingham.
The Effects of Functional Knee Bracing and Taping on the
Tibiofemoral Joint in Athletes With an ACL-deficient Knee
Aims: The aims of this study were to determine the usefulness of a functional knee brace
(FKB) or a spiral method of taping in modifying the impaired biomechanics of the ACL
deficient knees towards a safe and more normal pattern, and to assess any compensatory
changes at the ankle and hip joints following knee bracing or taping. The study also
aimed to compare the difference in gait patterns during simple· level walking and
treadmill activities for ACL-deficient subjects.
Methods: A prospective experimental study was carried out on 15 ACL-deficient and 15
carefully matched amateur athletes as controls. A comprehensive gait analysis study was
designed using a high frequency CODA-mpx30 gait analysis system, force platform and
electromyography (EMG) system. The study was carried out during simple level
walking, treadmill walking (3.6 Km/hr) and treadmill running (10 Km/hr) which we
describe as low and high level physical activities. Treatments investigated included a
functional knee brace (FKB) or a special spiral taping method that was applied to the
deficient knees. The temporospatial parameters, total range of motion (ROM), joint
position, kinetics and EMG parameters were recorded in the knee, ankle and hip joints in
different trials with different supports and the results were compared with the baseline
data of both the patients and the data derived from the control subjects.
Main Results: The FKB significantly reduced total ROM in the ACL-deficient subjects
for all levels of walking trials (P<O.05). The FKB significantly reduced peak knee
flexion during swing while walking on level ground, but increased maximum knee
flexion in swing during walking on the treadmill (P<O.05). Taping significantly
increased mean knee angle in stance in both walking modes (P<O.05). Neither FKBs nor
taping showed any angulatory kinematic effects on the knee joint during running on the
treadmill. The FKBs could significantly reduce the antero-posterior (A-P) displacement
of the tibia relative to the femur during level walking mostly in the swing phase.
Wearing a brace did not reduce the knee extensor moments, but significantly reduced the
hip flexor moments. Taping, however, had no significant effects on knee moment, but
increased the generation and absorption of ankle power and decreased hip generation
power. Bracing reduced the "support moment" and "support power" in the lower limb,
but taping did not change them. No quadriceps avoidance gait pattern was found in this
study and the patients showed an extensor knee moment througho,ut the stance phase.
The gastrocnemius muscle was found to have a principal role in the ACL-deficient
subjects and wearing a FKB could significantly activate the gastrocnemius muscles
earlier in the ACL-deficient subjects, although no effects on peak activity of the muscle
were demonstrated.
Conclusion: It can be concluded that the functional knee brace used in this study did not
show any harmful effects in ACL-deficient knees. It was helpful particularly for low
force activities such as level walking. The brace was as effective for walking on the
treadmill as walking on level ground although some kinematic changes exist between
these two different activities. Taping, however, is not recommended for ACL-deficient
knees. Since the ACL-deficient subjects showed good knee control in most running
trials, there would appear to be a need for more strenuous activities and these are
strongly recommended.
iv
..
ABREVIA TIONS
ABBREVIATIONS·
AbdlAdd Abduction!A dduction
AntIPost Anterior - Posterior
A-P Anterior - Posterior
ACL Anterior Cruciate Ligament
ACL-reconst. Anterior Cruciate Ligament-reconstruction
ADL Activities of Daily Living
ASIS Anterior Superior Iliac Spine
CODA Cartesian Optoelectronic Dynamic Antropometer
D.F. Dorsi Flexion
Flex.lExt. Flexion!Extension
FKB Functional Knee Brace
Gastroc. Gastrocnemius
GRF Ground Reaction Force
HS Heel Strike
Int/Ext Rot. Internal/External Rotation
IC Initial Contact
Int/ext Rot. Internal/External Rotation
LED Light-Emitting Diode
LR Loading Response
Lt. Left
Max. Maximum
MCL Medial Collateral Ligament
Med. Hamst. Medial Hamstring
MMT Manual Muscle Testing
N Newton
P.F. Plantar Flexion
PSIS Posterior Superior Iliac Spine
QAG Quadriceps Avoidance Gait
Rect. Fern. Rectus Femoris
Rntrb. Running on the treadmill with brace
Rntrn. Running on the treadmill without brace
Rntrtp. Running on the treadmill with tape
ROM Range Of Motion
Rt. Right
SD Standard Deviation
St. Stance
Sw. Swing
Val.Nar. Valgus / Varus
Vast. Med. Vastus Medialis
W Watts (unit of power)
W.B. Weight Bearing
N.W.B. Non Weight Bearing
Wkgrnb. Walking on level ground with brace
Wkgrn. Walking on level ground without brace
Wkgrtp. Walking on level ground with tape
Wktrb. Walking on the treadmill with brace .
Wktrn. Walking on the treadmi II without brace
Wktrtp. Walking on the treadmill with tape
v
ACKNOWLEDGEMENTS
ACKNOWLEDGEMENTS
To be able to carry out this work, lowe a debt of sincere gratitude to many people.
Firstly, my thanks must go at the Division of Orthopaedic & Accident Surgery and
the Centre for Sports Medicine, The University of Nottingham. I acknowledge an
enormous debt of gratitude to Professor W Angus Wallace for all his unfailing
kindness and supervision in the course of the preparation of the thesis, and for his
encouragement, endless guidance and support throughout the project. My sincere
thanks are also due to Mr Forster, Consultant Orthopaedic Surgeon, who did his best
as Clinical Director of the project and provided the ACL-deficient patients for the
study. The author wishes to thank Miss Brigitte Scammell, Head·ofthe Division, for
her encouragement and financial support, which enabled the author to take part in the
ESMAC Conference. I am also extremely grateful to Dr. Duvey, the statistician of
the Trent Institute, Faculty of Medicine and Health Sciences for his great help and to
Dr. Mark Batt for his guidance and feedback. The investigator wishes to thank all the
staff of the Division, particularly Miss Joanne Hallam-Allsop, the Departmental
Secretary, for all her patience and kindness; To Dr. Joanna Ford, researcher in the
Department for her great help in correction and revision of the thesis; To the library
staff of the University and the Faculty of Health and Medical Sciences for their help
and courtesy and for the care and consideration they have shown. A great thank you
to all of the ACL-deficient patients and volunteers who took part in the pilot and
final study for their tolerance in having their gait measured on more than one
occasion.
Secondly, in preparing this thesis I am' indebted to many people in various places,
mainly outside of Nottingham. Therefore, I would like to thank all Charnwood
Dynamics (CODA, Loughborough) staff, especially Mr David Mitchelson and Mr
Andrew Ward, who have supported me providing the latest version of the Coda
software. My endless thanks and appreciation goes to Mr Phil Pickering, the
Charnwood Dynamics' mathematical software engineer who has been with the
author from the beginning to the end of the project, and the thesis could not have
been completed without his help. My very sincere thanks are due to Mrs. Rose
MacDonald (the former Director of Crystal Palace Club, London), for her great help
for instruction to the author in the method of taping, and to Professor Roger
vi
ACKNOWLEDGEMENTS
Woledge, Director and Professor of Experimental Physiology, and his assistant, Mr
Matthew Thornton, Research Physiotherapist (Stanmore-, London), for their help in
making a suitable marker placement set-up for this study. I re~eived the generous
help and benefited from Dr Paul DeVita, Associate Professor in Exercise and Sports
Science and Biomechanics (East Carolina University, USA), to whom I am very
much in debted. Thank you for his hospitality at the time I was there to obtain his
help in interpreting the data, and very great thanks for the continuou~ support and
guidance I have received from him via e-mail for more than two years. He really
acted as a joint supervisor for my work.
Thirdly, carrying out a thesis is not possible without financial support. The financial
support for this work was provided by few sources; The Iranian Ministry of Health
and Medical Education, and particularly Shahid Beheshti University, to which I am
much obliged who kindly provided my tuition fees and the cost of living for me and
my family. In England, a great tribute to mediUK on behalf of the DonJoy Company
(USA), who generously provided the braces and taping consumables and always
supported the project. My thanks and appreciation again to mediUK for kindly
funding for my trips to Sweden and USA to take part in a conference and to enable
me to visit Dr DeVita. Thanks also to the Department of Physiotherapy at the City
Hospital, Nottingham, particularly Mr Andrew Kerr, Lecturer in physiotherapy and
the manager of the Gait Laboratory, for his permission in using the CODA mpx30
system.
Fourth, a compliment to my wife Fatemeh and my daughter Marzieh, and my family
and friends in Iran, for their invaluable moral and practical support and patience in
enduring my work on this thesis. I confess that it would not have been possible to
finish this thesis without their continued encouragement. They tolerated what others
would surely have found intolerable.
Fifth, I am beholden to a number of friends and reviewers for criticisms and
suggestions, whose memories I will never forget. However, the views expressed here
are the author's own. For all this work lacks, and for any rem~ining mistakes, he
alone is responsible.
Finally, and most of all, my great thanks are to God for giving me health and
continuing inspiration in carrying out this work.
vii
DECLARATION
/
)
/
DECLARATION
This thesis was carried out while I was in registered candidature. The
studies described and presented in this thesis are the original work of
the author, except where authors in the literature are cited.
viii
LIST OF FIGURES
LIST OF FIGURES·
Figure 1-1 Anterior and Posterior Views of the Knee Joint. ........................................... 12
Figure 1-2 Schematic Picture of Four-Bar Linkage in the Knee Joint. ........................... 14
Figure 2-1 Three Types of Knee Braces .......................................................................... 37
Figure 2-2. Quadriceps Avoidance Gait Phenomenon .................................................... 63
Figure 2-3 Three Methods of Taping Used for Knee Injuries ......................................... 73
Figure 3-13 Schematic Positions of the Real and Virtual Markers ............................... 106
Figure 3-1 CODA-3 (The Old Version of CODA mpx30) ............................................ 114
Figure 3.2 CODA mpx30 Scanner Unit ......................................................................... 114
Figure 3.3 Two Types Force Platforms Used in This Study .......................................... 114
Figure 3-4 Electromyography Surface Electrodes & Transmitter Pack. ....................... 115
Figure 3-5 Treadmill Used in This Study ...................................................................... 115
Figure 3-6 Drive Boxes and LED Markers Used in This Study .................................... 116
Figure 3-7 Legend DonJoy Functional Knee Brace (FKB) Used in This Study ........... 116
Figure 3-8 Running on the Treadmill with Taped ACL-Deficient Knee ....................... 117
Figure 3-9 Five Stag;es of Taping Used in This Study ................................................... 118
Figure 3-10 Coda's Unilateral Marker Placement. ........................................................ 119
Figure 3-11 Schematic Figure of the Clustering Marker Placement Method Used in This
Study ....................................................................................................................... 117
F' '
Igure 3-12 Non-Collinear Markers ............................................................................... 104
Figure 4-1 Histograms of the "Repeatability Test" With Coda mpx 30 Gait Analysis. 125
Figure 4~2 Consistency of the Kinematic and EMG Data during Running on the
Treadmill ................................................................................................................. 132
Figure 5-1 Boxplots Showing the Physical Profile of Study Participants ..................... 135
Figure 5-2 "Temporospatial Gait Parameters" .............................................................. 140
Figure 5-3 Histograms Showing the Range of Motion (ROM) in the ACL-Deficient and
Control Subjects ........ ;. . ~ .......................................................................................... 148
Figure 5-4 "Support ROM" in the ACL-Deficient and Control Subjects ...................... 149
ix
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