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Adam NC, Smith CR, Herzog W, Amis AA, Arampatzis A, Taylor WR. In Vivo Strain Patterns in the Achilles Tendon During Dynamic Activities: A Comprehensive Survey of the Literature. SPORTS MEDICINE - OPEN 2023; 9:60. [PMID: 37466866 DOI: 10.1186/s40798-023-00604-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 07/02/2023] [Indexed: 07/20/2023]
Abstract
Achilles' tendon (AT) injuries such as ruptures and tendinopathies have experienced a dramatic rise in the mid- to older-aged population. Given that the AT plays a key role at all stages of locomotion, unsuccessful rehabilitation after injury often leads to long-term, deleterious health consequences. Understanding healthy in vivo strains as well as the complex muscle-tendon unit interactions will improve access to the underlying aetiology of injuries and how their functionality can be effectively restored post-injury. The goals of this survey of the literature with a systematic search were to provide a benchmark of healthy AT strains measured in vivo during functional activities and identify the sources of variability observed in the results. Two databases were searched, and all articles that provided measured in vivo peak strains or the change in strain with respect to time were included. In total, 107 articles that reported subjects over the age of 18 years with no prior AT injury and measured while performing functional activities such as voluntary contractions, walking, running, jumping, or jump landing were included in this review. In general, unclear anatomical definitions of the sub-tendon and aponeurosis structures have led to considerable confusion in the literature. MRI, ultrasound, and motion capture were the predominant approaches, sometimes coupled with modelling. The measured peak strains increased from 4% to over 10% from contractions, to walking, running, and jumping, in that order. Importantly, measured AT strains were heavily dependent on measurement location, measurement method, measurement protocol, individual AT geometry, and mechanical properties, as well as instantaneous kinematics and kinetics of the studied activity. Through a comprehensive review of approaches and results, this survey of the literature therefore converges to a united terminology of the structures and their common underlying characteristics and presents the state-of-knowledge on their functional strain patterns.
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Affiliation(s)
- Naomi C Adam
- Institute for Biomechanics, ETH Zürich, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - Colin R Smith
- Institute for Biomechanics, ETH Zürich, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland
| | - Walter Herzog
- Human Performance Laboratory, Faculty of Kinesiology, The University of Calgary, Calgary, Canada
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - Adamantios Arampatzis
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, and Berlin School of Movement Science, Berlin, Germany
| | - William R Taylor
- Institute for Biomechanics, ETH Zürich, Leopold-Ruzicka-Weg 4, 8093, Zurich, Switzerland.
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Hoveizavi R, Gao F, Ramirez VJ, Shuman BR, Joiner JC, Fisher SJ. Compromised neuromuscular function of walking in people with diabetes: a narrative review. Diabetes Res Clin Pract 2023:110802. [PMID: 37356728 DOI: 10.1016/j.diabres.2023.110802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 04/18/2023] [Accepted: 06/22/2023] [Indexed: 06/27/2023]
Abstract
AIM This review summarizes recent studies that have investigated the neuromuscular dysfunction of walking in people with diabetes and its relationship to ulcer formation. METHODS A comprehensive electronic search in the database (Scopus, Web of Science, PsycINFO, ProQuest, and PubMed) was performed for articles pertaining to diabetes and gait biomechanics. RESULTS The Achilles tendon is thicker and stiffer in those with diabetes. People with diabetes demonstrate changes in walking kinematics and kinetics, including slower self-selected gait speed, shorter stride length, longer stance phase duration, and decreased ankle, knee, and metatarsophalangeal (MTP) joint range of motion. EMG is altered during walking and may reflect diabetes-induced changes in muscle synergies. Synergies are notable because they provide a more holistic pattern of muscle activations and can help develop better tools for characterizing disease progression. CONCLUSION Diabetes compromises neuromuscular coordination and function. The mechanisms contributing to ulcer formation are incompletely understood. Diabetes-related gait impairments may be a significant independent risk factor for the development of foot ulcers.
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Affiliation(s)
- Roya Hoveizavi
- Department of Kinesiology and Health promotions, University of Kentucky, Lexington, KY, USA.
| | - Fan Gao
- Department of Kinesiology and Health promotions, University of Kentucky, Lexington, KY, USA.
| | - Vanessa J Ramirez
- US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Benjamin R Shuman
- RR&D Center for Limb Loss and MoBility (CLiMB), Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Joshua C Joiner
- College of Medicine, University of Kentucky, Lexington, KY, USA.
| | - Simon J Fisher
- Division of Endocrinology, Diabetes and Metabolism, Dept. of Internal Medicine, University of Kentucky, Lexington, KY, USA.
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Vaidya R, Lake SP, Zellers JA. Effect of Diabetes on Tendon Structure and Function: Not Limited to Collagen Crosslinking. J Diabetes Sci Technol 2023; 17:89-98. [PMID: 35652696 PMCID: PMC9846394 DOI: 10.1177/19322968221100842] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Diabetes mellitus (DM) is associated with musculoskeletal complications-including tendon dysfunction and injury. Patients with DM show altered foot and ankle mechanics that have been attributed to tendon dysfunction as well as impaired recovery post-tendon injury. Despite the problem of DM-related tendon complications, treatment guidelines specific to this population of individuals are lacking. DM impairs tendon structure, function, and healing capacity in tendons throughout the body, but the Achilles tendon is of particular concern and most studied in the diabetic foot. At macroscopic levels, asymptomatic, diabetic Achilles tendons may show morphological abnormalities such as thickening, collagen disorganization, and/or calcific changes at the tendon enthesis. At smaller length scales, DM affects collagen sliding and discrete plasticity due to glycation of collagen. However, how these alterations translate to mechanical deficits observed at larger length scales is an area of continued investigation. In addition to dysfunction of the extracellular matrix, tendon cells such as tenocytes and tendon stem/progenitor cells show significant abnormalities in proliferation, apoptosis, and remodeling capacity in the presence of hyperglycemia and advanced glycation end-products, thus contributing to the disruption of tendon homeostasis and healing. Improving our understanding of the effects of DM on tendons-from molecular pathways to patients-will progress toward targeted therapies in this group at high risk of foot and ankle morbidity.
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Affiliation(s)
- Rachana Vaidya
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | - Jennifer A. Zellers
- Washington University School of
Medicine, St. Louis, MO, USA
- Jennifer A. Zellers, PT, DPT, PhD,
Washington University School of Medicine, 4444 Forest Park Ave., Suite
1101, St. Louis, MO 63108, USA.
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Zhao J, Luo M, Liang G, Pan J, Han Y, Zeng L, Yang W, Liu J. What Factors Are Associated with Symptomatic Rotator Cuff Tears: A Meta-analysis. Clin Orthop Relat Res 2022; 480:96-105. [PMID: 34424222 PMCID: PMC8673964 DOI: 10.1097/corr.0000000000001949] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tears are common. A previous systematic review reported on factors associated with rotator cuff tears; however, it included relatively few studies and few variables, and in addition, it had considerable heterogeneity. To identify the factors associated with symptomatic rotator cuff tears and to help guide clinicians to potentially modifiable factors, we felt a broader and more inclusive meta-analysis would be useful. QUESTIONS/PURPOSES In this systematic review and meta-analysis, we asked what (1) demographic, (2) disease, and (3) imaging factors are associated with symptomatic rotator cuff tears? METHODS PubMed, Embase, and Web of Science were searched, and the search period were from the inception of each database through February 2021. The keywords included "risk factor," "rotator cuff injury," "rotator cuff tears," and "rotator cuff tendinitis." All comparative studies on symptomatic rotator cuff tears were included. We considered that the diagnosis of rotator cuff tear could be made by any imaging tool (MRI or ultrasound). We considered either partial- or full-thickness tears to be a rotator cuff tear. No language restrictions were applied. Twenty-six articles from 14 countries involving 9809 individuals, consisting of 3164 patients and 6645 controls, were included. The Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality (AHRQ) scale were used to evaluate the risk of bias of the included studies, and the highest scores were 9 and 11, respectively. The Newcastle-Ottawa Scale was used for retrospective comparative studies, and the AHRQ was used to evaluate prospective comparative studies. The eight retrospective comparative studies we included were scored from 4 to 9. The quality score of the 18 prospective comparative studies ranged from 6 to 9. Publication bias was explored using the Egger test. Heterogeneity was estimated using the I2 value. If there was no heterogeneity (I2 ≤ 50%), a fixed-effects model was used to determine the overall effect size; if there was heterogeneity (I2 > 50%), a random-effects model was used to merge the effect values. A meta-analysis was performed with RevMan 5.3, and the risk ratio (RR) and weighted mean difference of related factors were calculated. RESULTS Our meta-analysis identified the following demographic factors associated with an increased risk of rotator cuff tears: older age (mean difference 3.1 [95% CI 1.4 to 4.8]; p < 0.001), greater BMI (mean difference 0.77 [95% CI 0.37 to 1.17]; p < 0.001), smoking (RR 1.32 [95% CI 1.17 to 1.49]; p < 0.001), dominant arm (RR 1.15 [95% CI 1.06 to 1.24]; p < 0.001), greater height (mean difference 0.9 [95% CI 0.4 to 1.4]; p < 0.001), and heavier weight (mean difference 2.24 [95% CI 0.82 to 3.66]; p = 0.002). Regarding disease factors, we found that traumatic events (RR 1.91 [95% CI 1.40 to 2.54]; p < 0.001) and hypertension (RR 1.50 [95% CI 1.32 to 1.70]; p < 0.001) were associated with symptomatic rotator cuff tears. Regarding imaging factors, we found that the following three factors were associated with symptomatic rotator cuff tears: greater acromion index (mean difference 0.11 [95% CI 0.06 to 0.16]; p < 0.001), greater critical shoulder angle (mean difference 1.9 [95% CI 1.5 to 2.3]; p < 0.001), and smaller glenoid version angle (mean difference -1.3 [95% CI -1.9 to -0.8]; p < 0.001). We found no association between the patient's sex or the presence or absence of thyroid disease and the likelihood of a rotator cuff tear being present. CONCLUSION This study identified several factors associated with symptomatic rotator cuff tears, including blood glucose, blood pressure, weight, and smoking. Clinicians may seek to modify these factors, possibly in patients with symptomatic rotator cuff tears, but also in symptomatic patients who have not yet been diagnosed with rotator cuff tears because there would be no harm or risk associated with modifying any of the factors we identified. Future research should further study whether addressing these factors can delay the progression and size of rotator cuff tears.Level of Evidence Level III, prognostic study.
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Affiliation(s)
- Jinlong Zhao
- The Second School of Clinical Medical Sciences, Guangzhou University of Chinese Medicine, Guagnzhou, China
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
| | - Minghui Luo
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Guihong Liang
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Jianke Pan
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Yanhong Han
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Lingfeng Zeng
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Weiyi Yang
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Jun Liu
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
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Human Achilles tendon mechanical behavior is more strongly related to collagen disorganization than advanced glycation end-products content. Sci Rep 2021; 11:24147. [PMID: 34921194 PMCID: PMC8683434 DOI: 10.1038/s41598-021-03574-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/03/2021] [Indexed: 12/25/2022] Open
Abstract
Diabetes is associated with impaired tendon homeostasis and subsequent tendon dysfunction, but the mechanisms underlying these associations is unclear. Advanced glycation end-products (AGEs) accumulate with diabetes and have been suggested to alter tendon function. In vivo imaging in humans has suggested collagen disorganization is more frequent in individuals with diabetes, which could also impair tendon mechanical function. The purpose of this study was to examine relationships between tendon tensile mechanics in human Achilles tendon with accumulation of advanced glycation end-products and collagen disorganization. Achilles tendon specimens (n = 16) were collected from individuals undergoing lower extremity amputation or from autopsy. Tendons were tensile tested with simultaneous quantitative polarized light imaging to assess collagen organization, after which AGEs content was assessed using a fluorescence assay. Moderate to strong relationships were observed between measures of collagen organization and tendon tensile mechanics (range of correlation coefficients: 0.570-0.727), whereas no statistically significant relationships were observed between AGEs content and mechanical parameters (range of correlation coefficients: 0.020-0.210). Results suggest that the relationship between AGEs content and tendon tensile mechanics may be masked by multifactorial collagen disorganization at larger length scales (i.e., the fascicle level).
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Zhao J, Luo M, Liang G, Wu M, Pan J, Zeng LF, Yang W, Liu J. Risk Factors for Supraspinatus Tears: A Meta-analysis of Observational Studies. Orthop J Sports Med 2021; 9:23259671211042826. [PMID: 34660827 PMCID: PMC8516389 DOI: 10.1177/23259671211042826] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/08/2021] [Indexed: 12/19/2022] Open
Abstract
Background: The pathogenesis of rotator cuff tears remains unclear, and there is a lack of high-quality evidence-based research on the risk factors for supraspinatus tears. Purpose: To explore 10 potential risk factors for supraspinatus muscle tears. Study Design: Systematic review; Level of evidence, 3. Methods: This review was conducted according to the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines. PubMed, Embase, and Web of Science were searched for cohort, case-control and cross-sectional studies published before January 2021 on supraspinatus tears. The following potential risk factors were analyzed: age, body mass index, male sex, female sex, arm dominance, diabetes mellitus, smoking, hypertension, thyroid disease, and the critical shoulder angle (CSA). Risk ratios (RRs) or weighted mean differences (WMDs) of related risk were calculated. The Egger test was used to evaluate publication bias. Results: A total of 9 articles from 8 countries were included; among the 3240 patients, 687 were included in the supraspinatus tear group, and 2553 were included in the nonsupraspinatus tear group. The meta-analysis showed that older age (WMD, 3.36 [95% confidence interval (CI), 0.53-6.20]; P = .02), male sex (RR, 0.87 [95% CI, 0.78-0.97]; P = .01), smoking (RR, 2.21 [95% CI, 1.56-3.14]; P < .00001), diabetes (RR, 1.67 [95% CI, 1.03-2.70]; P = .04), hypertension (RR, 1.51 [95% CI, 1.16-1.97]; P = .002), and the CSA (WMD, 2.25 [95% CI, 1.39-3.12]; P < .00001) were risk factors for supraspinatus tears. Conclusion: Older age, male sex, smoking, diabetes, hypertension, and a higher CSA were found to be risk factors for supraspinatus tears in this meta-analysis review. Identifying risk factors for supraspinatus tears early can help clinicians identify these high-risk patients and choose appropriate treatments.
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Affiliation(s)
- Jinlong Zhao
- The Second School of Clinical Medical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China.,Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China
| | - Minghui Luo
- Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China.,The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, People's Republic of China
| | - Guihong Liang
- Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China.,The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, People's Republic of China
| | - Ming Wu
- The Second School of Clinical Medical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, People's Republic of China.,Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China
| | - Jianke Pan
- Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China.,The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, People's Republic of China
| | - Ling-Feng Zeng
- Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China.,The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, People's Republic of China
| | - Weiyi Yang
- Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China.,The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, People's Republic of China
| | - Jun Liu
- Guangdong Academy of Traditional Chinese Medicine, Research Team on Bone and Joint Degeneration and Injury, Guangzhou, People's Republic of China.,The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, People's Republic of China.,Guangdong Second Traditional Chinese Medicine Hospital (Guangdong Province Engineering Technology Research Institute of Traditional Chinese Medicine), Guangzhou, People's Republic of China
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7
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Squier K, Scott A, Hunt MA, Brunham LR, Wilson DR, Screen H, Waugh CM. The effects of cholesterol accumulation on Achilles tendon biomechanics: A cross-sectional study. PLoS One 2021; 16:e0257269. [PMID: 34529718 PMCID: PMC8445482 DOI: 10.1371/journal.pone.0257269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022] Open
Abstract
Familial hypercholesterolemia, a common genetic metabolic disorder characterized by high cholesterol levels, is involved in the development of atherosclerosis and other preventable diseases. Familial hypercholesterolemia can also cause tendinous abnormalities, such as thickening and xanthoma (tendon lipid accumulation) in the Achilles, which may impede tendon biomechanics. The objective of this study was to investigate the effect of cholesterol accumulation on the biomechanical performance of Achilles tendons, in vivo. 16 participants (10 men, 6 women; 37±6 years) with familial hypercholesterolemia, diagnosed with tendon xanthoma, and 16 controls (10 men, 6 women; 36±7 years) underwent Achilles biomechanical assessment. Achilles biomechanical data was obtained during preferred pace, shod, walking by analysis of lower limb kinematics and kinetics utilizing 3D motion capture and an instrumented treadmill. Gastrocnemius medialis muscle-tendon junction displacement was imaged using ultrasonography. Achilles stiffness, hysteresis, strain and force were calculated from displacement-force data acquired during loading cycles, and tested for statistical differences using one-way ANOVA. Statistical parametric mapping was used to examine group differences in temporal data. Participants with familial hypercholesterolemia displayed lower Achilles stiffness compared to the control group (familial hypercholesterolemia group: 87±20 N/mm; controls: 111±18 N/mm; p = 0.001), which appeared to be linked to Achilles loading rate rather than an increased strain (FH: 5.27±1.2%; controls: 4.95±0.9%; p = 0.413). We found different Achilles loading patterns in the familial hypercholesterolemia group, which were traced to differences in the centre of pressure progression that affected ankle moment. This finding may indicate that individuals with familial hypercholesterolemia use different Achilles loading strategies. Participants with familial hypercholesterolemia also demonstrated significantly greater Achilles hysteresis than the control group (familial hypercholesterolemia: 57.5±7.3%; controls: 43.8±10%; p<0.001), suggesting that walking may require a greater metabolic cost. Our results indicate that cholesterol accumulation could contribute to reduced Achilles function, while potentially increasing the chance of injury.
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Affiliation(s)
- Kipling Squier
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Alexander Scott
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Michael A. Hunt
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Liam R. Brunham
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - David R. Wilson
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hazel Screen
- School of Engineering & Materials Science, Queen Mary University of London, London, United Kingdom
| | - Charlie M. Waugh
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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Waugh CM, Scott A. Substantial Achilles adaptation following strength training has no impact on tendon function during walking. PLoS One 2021; 16:e0255221. [PMID: 34324575 PMCID: PMC8320898 DOI: 10.1371/journal.pone.0255221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/12/2021] [Indexed: 11/18/2022] Open
Abstract
Tendons are responsive to mechanical loading and their properties are often the target of intervention programs. The tendon's mechanical properties, particularly stiffness, also govern its function, therefore changes to these properties could have substantial influence on energy-saving mechanisms during activities utilizing the stretch-shortening cycle. We investigated Achilles tendon (AT) function in vivo during walking with respect to a training intervention that elicited significant increases in AT stiffness. 14 men and women completed 12-weeks of isometric plantarflexor strength training that increased AT stiffness, measured during isometric MVC, by ~31%. Before and after the intervention, participants walked shod at their preferred velocity on a fully-instrumented treadmill. Movement kinematics, kinetics and displacement of the gastrocnemius medialis muscle-tendon junction were captured synchronously using 3D motion capture and ultrasound imaging, respectively. A MANOVA test was used to examine changes in AT force, stress, strain, stiffness, Young's modulus, hysteresis and strain energy, measured during walking, before and following strength training. All were non-significant for a main effect of time, therefore no follow-up statistical tests were conducted. Changes in joint kinematics, tendon strain, velocity, work and power and muscle activity during the stance phase were assessed with 1D statistical parametric mapping, all of which also demonstrated a lack of change in response to the intervention. This in vivo examination of tendon function in walking provides an important foundation for investigating the functional consequences of training adaptations. We found substantial increases in AT stiffness did not impact on tendon function during walking. AT stiffness measured during walking, however, was unchanged with training, which suggests that increases in stiffness may not be evident across the whole force-elongation relation, a finding which may help explain previously mixed intervention results and guide future investigations in the functional implications of tendon adaptation.
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Affiliation(s)
- C. M. Waugh
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- * E-mail:
| | - A. Scott
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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9
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Afolabi BI, Idowu BM, Onigbinde SO. Achilles tendon degeneration on ultrasound in type 2 diabetic patients. J Ultrason 2021; 20:e291-e299. [PMID: 33500797 PMCID: PMC7830069 DOI: 10.15557/jou.2020.0051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022] Open
Abstract
Aim of study The main goal of this study was to compare the various degenerative changes in the Achilles tendon of type 2 diabetic patients to that of controls. The influence of diabetic peripheral neuropathy, duration of diabetes mellitus, age, and body mass index on the occurrence of degenerative changes was also evaluated. Materials and methods The Achilles tendons of both limbs were evaluated with high-resolution ultrasound in 80 type 2 diabetics and 80 age/sex-matched controls. A 10 g Semmes Weinstein monofilament was used to examine for peripheral neuropathy. Anthropometric measurements and biochemical assessment of glycemic control (fasting plasma glucose and glycated hemoglobin) were also done. Results The mean age of type 2 diabetic subjects and healthy controls was 60.9 ± 10.3 years (range 41–79 years) and 61.0 ± 10.3 years (range 40–79 years), respectively (p = 0.963). The median duration of diabetes mellitus was 42.0 months (range = 1–456 months). The prevalence of degenerative changes (calcifications, disorganized fibers and/or hypoechoic foci) was significantly higher in type 2 diabetic subjects than controls in both the right (55.0% vs. 18.8%, p <0.001) and left (52.5% vs. 18.8%, p <0.001) feet. Conclusion The Achilles tendons of type 2 diabetic subjects have significantly more degenerative changes than their age/sex-matched controls in our locality. Disorganized Achilles tendon fibers occur significantly more often among male than female type 2 diabetic subjects. Disorganization of Achilles tendon fibers and hypoechoic foci are significantly more prevalent in type 2 diabetic subjects with peripheral neuropathy than those without peripheral neuropathy. Body mass index did not affect the occurrence of degenerative changes in the Achilles tendon of participants.
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Affiliation(s)
- Babalola Ishamel Afolabi
- Department of Radiology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
| | - Bukunmi Michael Idowu
- Department of Radiology, Union Diagnostics and Clinic Services Plc, Yaba, Lagos, Nigeria
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10
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Techniques for In Vivo Measurement of Ligament and Tendon Strain: A Review. Ann Biomed Eng 2020; 49:7-28. [PMID: 33025317 PMCID: PMC7773624 DOI: 10.1007/s10439-020-02635-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
Abstract
The critical clinical and scientific insights achieved through knowledge of in vivo musculoskeletal soft tissue strains has motivated the development of relevant measurement techniques. This review provides a comprehensive summary of the key findings, limitations, and clinical impacts of these techniques to quantify musculoskeletal soft tissue strains during dynamic movements. Current technologies generally leverage three techniques to quantify in vivo strain patterns, including implantable strain sensors, virtual fibre elongation, and ultrasound. (1) Implantable strain sensors enable direct measurements of tissue strains with high accuracy and minimal artefact, but are highly invasive and current designs are not clinically viable. (2) The virtual fibre elongation method tracks the relative displacement of tissue attachments to measure strains in both deep and superficial tissues. However, the associated imaging techniques often require exposure to radiation, limit the activities that can be performed, and only quantify bone-to-bone tissue strains. (3) Ultrasound methods enable safe and non-invasive imaging of soft tissue deformation. However, ultrasound can only image superficial tissues, and measurements are confounded by out-of-plane tissue motion. Finally, all in vivo strain measurement methods are limited in their ability to establish the slack length of musculoskeletal soft tissue structures. Despite the many challenges and limitations of these measurement techniques, knowledge of in vivo soft tissue strain has led to improved clinical treatments for many musculoskeletal pathologies including anterior cruciate ligament reconstruction, Achilles tendon repair, and total knee replacement. This review provides a comprehensive understanding of these measurement techniques and identifies the key features of in vivo strain measurement that can facilitate innovative personalized sports medicine treatment.
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Metz VR, Andrade RM, Machado-Lima A, Amadio AC, Serrão JC, Greve JMD, Alonso AC. INFLUENCE OF DIABETIC NEUROPATHY ON GAIT COMPLEXITY. REV BRAS MED ESPORTE 2020. [DOI: 10.1590/1517-869220202605219295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Introduction: Human gait is a complex movement dependent on multilevel neural control, which allows a consistent, regular and complex periodic pattern, properties that characterize it as a nonlinear system. Sensory and motor deficits, with diminished proprioceptive responses, may reduce the adaptive capacity of the system, as demonstrated in Parkinson's, Alzheimer's and Huntington's diseases. However, little is known about the effect of peripheral diabetic neuropathy on these responses. Objectives: To analyze the influence of peripheral diabetic neuropathy on entropy in different gait environments. Methods: Ten elderly patients, with and without a diagnosis of peripheral diabetic neuropathy, walked on a treadmill (initial speed of 3 km/h, with 0.5 km/h increments every 5 minutes up to the speed of 5 km/h) to record center of mass acceleration in the vertical, mediolateral and anteroposterior components throughout the test. The sample entropy of the three vectors was calculated for each test speed. Results: The vertical component did not show any statistically significant differences. The mediolateral component showed statistically significant difference for the factors group, speed, and interaction between factors (group and speed). The anteroposterior component showed statistically significant differences for the group factor, but not for speed and interaction between factors (group and speed). Effect sizes classified as large were found in all the comparisons. Conclusions: Peripheral diabetic neuropathy produced changes in the ability to adapt to changes in the environment during gait, probably due to changes in the complexity of the multilevel neural control system, which depends on motor and sensory feedback, known to be affected by peripheral diabetic neuropathy. Level of Evidence II; Diagnostic studies - Investigating a diagnostic test.
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Petrovic M, Maganaris CN, Bowling FL, Boulton AJM, Reeves ND. Vertical displacement of the centre of mass during walking in people with diabetes and diabetic neuropathy does not explain their higher metabolic cost of walking. J Biomech 2019; 83:85-90. [PMID: 30473134 DOI: 10.1016/j.jbiomech.2018.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 11/15/2018] [Accepted: 11/15/2018] [Indexed: 11/29/2022]
Abstract
People with diabetes display biomechanical gait alterations compared to controls and have a higher metabolic cost of walking (CoW), but it remains unknown whether differences in the vertical displacement of the body centre of mass (CoM) may play a role in this higher CoW. The aim of this study was to investigate vertical CoM displacement (and step length as a potential underpinning factor) as an explanatory factor in the previously observed increased CoW with diabetes. Thirty-one non-diabetic controls (Ctrl); 22 diabetic patients without peripheral neuropathy (DM) and 14 patients with moderate/severe Diabetic Peripheral Neuropathy (DPN), underwent gait analysis using a motion analysis system and force plates while walking at a range of matched speeds between 0.6 and 1.6 m/s. Vertical displacement of the CoM was measured over the gait cycle, and was not different in either diabetes patients with or without diabetic peripheral neuropathy compared to controls across the range of matched walking speeds examined (at 1 m/s: Ctrl: 5.59 (SD: 1.6), DM: 5.41 (1.63), DPN: 4.91 (1.66) cm; p > 0.05). The DPN group displayed significantly shorter steps (at 1 m/s: Ctrl: 69, DM: 67, DPN: 64 cm; p > 0.05) and higher cadence (at 1 m/s: Ctrl: 117 (SD1.12), DM: 119 (1.08), DPN: 122 (1.25) steps per minute; p > 0.05) across all walking speeds compared to controls. The vertical CoM displacement is therefore unlikely to be a factor in itself that contributes towards the higher CoW observed recently in people with diabetic neuropathy. The higher CoW in patients with diabetes may not be explained by the CoM displacement, but rather may be more related to shorter step lengths, increased cadence and the associated increased internal work and higher muscle forces developed by walking with more flexed joints.
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Affiliation(s)
- M Petrovic
- Research Centre for Musculoskeletal Science & Sports Medicine, School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, UK
| | - C N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University, UK
| | - F L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, UK
| | - A J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - N D Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, School of Healthcare Science, Faculty of Science & Engineering, Manchester Metropolitan University, UK.
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13
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Henderson AD, Johnson AW, Ridge ST, Egbert JS, Curtis KP, Berry LJ, Bruening DA. Diabetic Gait Is Not Just Slow Gait: Gait Compensations in Diabetic Neuropathy. J Diabetes Res 2019; 2019:4512501. [PMID: 31815148 PMCID: PMC6878800 DOI: 10.1155/2019/4512501] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/05/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Neuropathic complications from diabetes mellitus affect multiple nerve types and may manifest in gait. However, gait compensations are still poorly understood, as narrow analyses and lack of speed controls have contributed to conflicting or equivocal results. PURPOSE To evaluate gait mechanics and energetics in diabetic peripheral polyneuropathy. METHODS Instrumented gait analysis was performed on 14 participants with diabetic peripheral polyneuropathy and 14 matched controls, walking at 1.0 m/s. A full-body model with a multisegment foot was used to calculate inverse dynamics and analyze sagittal plane metrics and time series waveforms across stance phase. RESULTS Alterations included increased hip and knee flexion in early stance followed by a prolonged hip extension moment in midstance. Late stance ankle dorsiflexion and power absorption were increased, and final push-off was delayed and truncated. CONCLUSION A neuropathic diabetic gait shares important similarities to a mild crouch gait with weakness/dysfunction in the foot and ankle. This study highlights two main compensation mechanisms that have been overlooked in previous literature. First, increased triceps surae stretch in terminal stance may be used to increase proprioception and/or energy storage, while a prolonged hip extension moment in midstance compensates for a limited push-off. These result in an overall workload shift from distal to proximal joints. Clinical assessment, monitoring, and treatment of neuropathy may benefit by focusing on these specific functional alterations.
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Affiliation(s)
| | - A. Wayne Johnson
- Exercise Sciences Department, Brigham Young University, Provo, UT, USA
| | - Sarah T. Ridge
- Exercise Sciences Department, Brigham Young University, Provo, UT, USA
| | | | - Kevin P. Curtis
- Exercise Sciences Department, Brigham Young University, Provo, UT, USA
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Petrovic M, Maganaris CN, Deschamps K, Verschueren SM, Bowling FL, Boulton AJM, Reeves ND. Altered Achilles tendon function during walking in people with diabetic neuropathy: implications for metabolic energy saving. J Appl Physiol (1985) 2018; 124:1333-1340. [PMID: 29420151 DOI: 10.1152/japplphysiol.00290.2017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The Achilles tendon (AT) has the capacity to store and release elastic energy during walking, contributing to metabolic energy savings. In diabetes patients, it is hypothesized that a stiffer Achilles tendon may reduce the capacity for energy saving through this mechanism, thereby contributing to an increased metabolic cost of walking (CoW). The aim of this study was to investigate the effects of diabetes and diabetic peripheral neuropathy (DPN) on the Achilles tendon and plantarflexor muscle-tendon unit behavior during walking. Twenty-three nondiabetic controls (Ctrl); 20 diabetic patients without peripheral neuropathy (DM), and 13 patients with moderate/severe DPN underwent gait analysis using a motion analysis system, force plates, and ultrasound measurements of the gastrocnemius muscle, using a muscle model to determine Achilles tendon and muscle-tendon length changes. During walking, the DM and particularly the DPN group displayed significantly less Achilles tendon elongation (Ctrl: 1.81; DM: 1.66; and DPN: 1.54 cm), higher tendon stiffness (Ctrl: 210; DM: 231; and DPN: 240 N/mm), and higher tendon hysteresis (Ctrl: 18; DM: 21; and DPN: 24%) compared with controls. The muscle fascicles of the gastrocnemius underwent very small length changes in all groups during walking (~0.43 cm), with the smallest length changes in the DPN group. Achilles tendon forces were significantly lower in the diabetes groups compared with controls (Ctrl: 2666; DM: 2609; and DPN: 2150 N). The results strongly point toward the reduced energy saving capacity of the Achilles tendon during walking in diabetes patients as an important factor contributing to the increased metabolic CoW in these patients. NEW & NOTEWORTHY From measurements taken during walking we observed that the Achilles tendon in people with diabetes and particularly people with diabetic peripheral neuropathy was stiffer, was less elongated, and was subject to lower forces compared with controls without diabetes. These altered properties of the Achilles tendon in people with diabetes reduce the tendon's energy saving capacity and contribute toward the higher metabolic energy cost of walking in these patients.
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Affiliation(s)
- M Petrovic
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University , Manchester , United Kingdom
| | - C N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University , Liverpool , United Kingdom
| | - K Deschamps
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven , Belgium
| | - S M Verschueren
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven , Belgium
| | - F L Bowling
- Faculty of Medical and Human Sciences, University of Manchester , Manchester , United Kingdom
| | - A J M Boulton
- Faculty of Medical and Human Sciences, University of Manchester , Manchester , United Kingdom.,Diabetes Research Institute, University of Miami , Miami, Florida
| | - N D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University , Manchester , United Kingdom
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15
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Impact of ankle foot orthosis stiffness on Achilles tendon and gastrocnemius function during unimpaired gait. J Biomech 2017; 64:145-152. [PMID: 29037441 DOI: 10.1016/j.jbiomech.2017.09.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 07/19/2017] [Accepted: 09/19/2017] [Indexed: 11/23/2022]
Abstract
Ankle foot orthoses (AFOs) are designed to improve gait for individuals with neuromuscular conditions and have also been used to reduce energy costs of walking for unimpaired individuals. AFOs influence joint motion and metabolic cost, but how they impact muscle function remains unclear. This study investigated the impact of different stiffness AFOs on medial gastrocnemius muscle (MG) and Achilles tendon (AT) function during two walking speeds. We performed gait analyses for eight unimpaired individuals. Each individual walked at slow and very slow speeds with a 3D printed AFO with no resistance (free hinge condition) and four levels of ankle dorsiflexion stiffness: 0.25Nm/°, 1Nm/°, 2Nm/°, and 3.7Nm/°. Motion capture, ultrasound, and musculoskeletal modeling were used to quantify MG and AT lengths with each AFO condition. Increasing AFO stiffness increased peak AFO dorsiflexion moment with decreased peak knee extension and peak ankle dorsiflexion angles. Overall musculotendon length and peak AT length decreased, while peak MG length increased with increasing AFO stiffness. Peak MG activity, length, and velocity significantly decreased with slower walking speed. This study provides experimental evidence of the impact of AFO stiffness and walking speed on joint kinematics and musculotendon function. These methods can provide insight to improve AFO designs and optimize musculotendon function for rehabilitation, performance, or other goals.
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16
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Jackson RW, Dembia CL, Delp SL, Collins SH. Muscle-tendon mechanics explain unexpected effects of exoskeleton assistance on metabolic rate during walking. ACTA ACUST UNITED AC 2017; 220:2082-2095. [PMID: 28341663 DOI: 10.1242/jeb.150011] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/21/2017] [Indexed: 12/22/2022]
Abstract
The goal of this study was to gain insight into how ankle exoskeletons affect the behavior of the plantarflexor muscles during walking. Using data from previous experiments, we performed electromyography-driven simulations of musculoskeletal dynamics to explore how changes in exoskeleton assistance affected plantarflexor muscle-tendon mechanics, particularly for the soleus. We used a model of muscle energy consumption to estimate individual muscle metabolic rate. As average exoskeleton torque was increased, while no net exoskeleton work was provided, a reduction in tendon recoil led to an increase in positive mechanical work performed by the soleus muscle fibers. As net exoskeleton work was increased, both soleus muscle fiber force and positive mechanical work decreased. Trends in the sum of the metabolic rates of the simulated muscles correlated well with trends in experimentally observed whole-body metabolic rate (R2=0.9), providing confidence in our model estimates. Our simulation results suggest that different exoskeleton behaviors can alter the functioning of the muscles and tendons acting at the assisted joint. Furthermore, our results support the idea that the series tendon helps reduce positive work done by the muscle fibers by storing and returning energy elastically. We expect the results from this study to promote the use of electromyography-driven simulations to gain insight into the operation of muscle-tendon units and to guide the design and control of assistive devices.
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Affiliation(s)
- Rachel W Jackson
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - Christopher L Dembia
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305, USA
| | - Scott L Delp
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305, USA.,Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Steven H Collins
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA.,Robotics Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA
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Lui PPY. Tendinopathy in diabetes mellitus patients-Epidemiology, pathogenesis, and management. Scand J Med Sci Sports 2017; 27:776-787. [PMID: 28106286 DOI: 10.1111/sms.12824] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 12/15/2022]
Abstract
Chronic tendinopathy is a frequent and disabling musculo-skeletal problem affecting the athletic and general populations. The affected tendon is presented with local tenderness, swelling, and pain which restrict the activity of the individual. Tendon degeneration reduces the mechanical strength and predisposes it to rupture. The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activation of the hypoxia-apoptosis-pro-inflammatory cytokines cascade, neurovascular ingrowth, increased production of neuromediators, and erroneous stem cell differentiation have been proposed. Many intrinsic and extrinsic risk/causative factors can predispose to the development of tendinopathy. Among them, diabetes mellitus is an important risk/causative factor. This review aims to appraise the current literature on the epidemiology and pathology of tendinopathy in diabetic patients. Systematic reviews were done to summarize the literature on (a) the association between diabetes mellitus and tendinopathy/tendon tears, (b) the pathological changes in tendon under diabetic or hyperglycemic conditions, and (c) the effects of diabetes mellitus or hyperglycemia on the outcomes of tendon healing. The potential mechanisms of diabetes mellitus in causing and exacerbating tendinopathy with reference to the major non-mutually exclusive hypotheses of the pathogenic mechanisms of chronic tendinopathy as reported in the literature are also discussed. Potential strategies for the management of tendinopathy in diabetic patients are presented.
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Affiliation(s)
- P P Y Lui
- Headquarter, Hospital Authority, Hong Kong SAR, China
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18
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Kalsi G, Fry NR, Shortland AP. Gastrocnemius muscle-tendon interaction during walking in typically-developing adults and children, and in children with spastic cerebral palsy. J Biomech 2016; 49:3194-3199. [PMID: 27545082 DOI: 10.1016/j.jbiomech.2016.07.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Our understanding of the interaction of muscle bellies and their tendons in individuals with muscle pathology is limited. Knowledge of these interactions may inform us of the effects of musculoskeletal pathologies on muscle-tendon dynamics and the subsequent neurological control strategies used in gait. Here, we investigate gastrocnemius muscle-tendon interaction in typically-developing (TD) adults and children, and in children with spastic cerebral palsy (SCP). METHODS We recruited six TD adults (4 female; mean age: 34 yrs. (24-54)), eight TD children (5 female; mean age: 10 yrs. (6-12)) and eight independently ambulant children with SCP (5 female; mean age 9 yrs. (6-12); 3 unilaterally-affected). A combination of 3D motion capture and 2D real-time ultrasound imaging were used to compute the gastrocnemius musculo-tendinous unit (MTU) length and estimate muscle belly and tendon lengths during walking. For the TD subjects, the measurements were made for heel-toe walking and voluntary toe-walking. RESULTS The gastrocnemius muscle bellies of children with SCP lengthened during single support (p = 0.003). In contrast, the muscle bellies of TD subjects did not demonstrate an increase in length over the period of single support under heel-toe or toe-walking conditions. CONCLUSION We observed lengthening of the gastrocnemius muscle bellies in children with SCP during single support, a phase of the gait cycle in which the muscle is reported consistently to be active. Repeated lengthening of muscle bellies while they are active may lead to muscle damage and have implications for the natural history of gait in this group.
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Affiliation(s)
- Gursharan Kalsi
- Clinical Physics, Barts Health NHS Trust, The Royal London Hospital, 56-76 Ashfield Street, Whitechapel, London E1 1BB, UK; One Small Step Gait Laboratory, Guy׳s and St. Thomas' NHS Foundation Trust, Guy׳s Hospital, London SE1 9RT, UK.
| | - Nicola R Fry
- One Small Step Gait Laboratory, Guy׳s and St. Thomas' NHS Foundation Trust, Guy׳s Hospital, London SE1 9RT, UK
| | - Adam P Shortland
- One Small Step Gait Laboratory, Guy׳s and St. Thomas' NHS Foundation Trust, Guy׳s Hospital, London SE1 9RT, UK; Department of Biomedical Engineering, Division of Imaging Sciences and Biomedical Engineering, King׳s College London, King׳s Health Partners,St. Thomas' Hospital, London SE1 7EH, UK
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19
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Oliva F, Piccirilli E, Berardi AC, Frizziero A, Tarantino U, Maffulli N. Hormones and tendinopathies: the current evidence. Br Med Bull 2016; 117:39-58. [PMID: 26790696 DOI: 10.1093/bmb/ldv054] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tendinopathies negatively affect the quality of life of millions of people, but we still do not know the factors involved in the development of tendon conditions. SOURCES OF DATA Published articles in English in PubMed and Google Scholar up to June 2015 about hormonal influence on tendinopathies onset. One hundred and two papers were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. AREAS OF AGREEMENT In vitro and in vivo, tenocytes showed changes in their morphology and in their functional properties according to hormonal imbalances. AREAS OF CONTROVERSY Genetic pattern, sex, age and comorbidities can influence the hormonal effect on tendons. GROWING POINTS The increasing prevalence of metabolic disorders prompts to investigate the possible connection between metabolic problems and musculoskeletal diseases. AREAS TIMELY FOR DEVELOPING RESEARCH The influence of hormones on tendon structure and metabolism needs to be further investigated. If found to be significant, multidisciplinary preventive and therapeutic strategies should then be developed.
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Affiliation(s)
- Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome 'Tor Vergata', Roma, Italy
| | - Eleonora Piccirilli
- School of Specialization of Orthopaedics and Traumatology, University of Rome 'Tor Vergata', Roma, Italy
| | - Anna C Berardi
- UOC Immunohematology and Transfusion Medicine Laboratories, Laboratory of Stem Cells, Spirito Santo Hospital, Pescara, Italy
| | - Antonio Frizziero
- Department of Physical and Rehabilitation Medicine, University of Padua, Padua, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome 'Tor Vergata', Roma, Italy
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, Queen Mary University of London Barts, London, UK The London School of Medicine and Dentistry, Mile End Hospital London, London, UK Department of Physical and Rehabilitation Medicine, University of Salerno, Fisciano, Italy
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20
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Jewson JL, Lambert GW, Storr M, Gaida JE. The sympathetic nervous system and tendinopathy: a systematic review. Sports Med 2016; 45:727-43. [PMID: 25655371 DOI: 10.1007/s40279-014-0300-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tendinopathy is a clinical diagnosis of localised tendon pain often confirmed by imaging findings. The pathophysiological cause of the pain is unknown and the sympathetic nervous system (SNS) may be implicated. OBJECTIVE To review what is known regarding the role of the SNS in human tendinopathy. STUDY SELECTION Published data describing sympathetic innervation or an index of sympathetic activity in human tendons were eligible for inclusion. DATA SOURCES Bibliographical databases (AMED, Biological Abstracts, CINAHL Plus, EMBASE, MEDLINE, Scopus, SPORTDiscus and Web of Science) were searched for relevant articles. Reference lists from included articles were screened for additional articles. STUDY APPRAISAL Studies were scored with a quality assessment tool to identify potential sources of bias. Each question had an explicit decision rule to guide assessment. RESULTS Nine case-control and four cross-sectional studies examined sympathetic innervation of tendons. There was evidence suggesting a lack of difference in sympathetic innervation of tendon proper between tendinopathy biopsies and healthy controls. In contrast, the paratendinous tissue showed evidence of increased sympathetic innervation in painful tendons. The most notable increase in SNS markers was seen in abnormal tenocytes from painful tendons. Data from two studies were suitable for meta-analysis. These heterogeneous studies revealed no difference in sympathetic innervation between painful and pain-free tendons. No studies recorded SNS activity in vivo. CONCLUSION Sympathetic innervation in painful tendons depends on tissue type. Abnormal tenocytes may have increased capacity for self-production of sympathetic neurotransmitters. Future insight may be gained by measuring global in vivo sympathetic drive in tendinopathy.
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Affiliation(s)
- Jacob L Jewson
- Central Medical School, Monash University, Melbourne, VIC, Australia,
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Petrovic M, Deschamps K, Verschueren SM, Bowling FL, Maganaris CN, Boulton AJM, Reeves ND. Is the metabolic cost of walking higher in people with diabetes? J Appl Physiol (1985) 2016; 120:55-62. [DOI: 10.1152/japplphysiol.00413.2015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/20/2015] [Indexed: 01/13/2023] Open
Abstract
People with diabetes walk slower and display biomechanical gait alterations compared with controls, but it remains unknown whether the metabolic cost of walking (CoW) is elevated. The aim of this study was to investigate the CoW and the lower limb concentric joint work as a major determinant of the CoW, in patients with diabetes and diabetic peripheral neuropathy (DPN). Thirty-one nondiabetic controls (Ctrl), 22 diabetic patients without peripheral neuropathy (DM), and 14 patients with moderate/severe DPN underwent gait analysis using a motion analysis system and force plates and treadmill walking using a gas analyzer to measure oxygen uptake. The CoW was significantly higher particularly in the DPN group compared with controls and also in the DM group (at selected speeds only) compared with controls, across a range of matched walking speeds. Despite the higher CoW in patients with diabetes, concentric lower limb joint work was significantly lower in DM and DPN groups compared with controls. The higher CoW is likely due to energetic inefficiencies associated with diabetes and DPN reflecting physiological and biomechanical characteristics. The lower concentric joint work in patients with diabetes might be a consequence of kinematic gait alterations and may represent a natural strategy aimed at minimizing the CoW.
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Affiliation(s)
- M. Petrovic
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
| | - K. Deschamps
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgium; and
| | - S. M. Verschueren
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgium; and
| | - F. L. Bowling
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - C. N. Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - A. J. M. Boulton
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - N. D. Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
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Couppé C, Svensson RB, Kongsgaard M, Kovanen V, Grosset JF, Snorgaard O, Bencke J, Larsen JO, Bandholm T, Christensen TM, Boesen A, Helmark IC, Aagaard P, Kjaer M, Magnusson SP. Human Achilles tendon glycation and function in diabetes. J Appl Physiol (1985) 2015; 120:130-7. [PMID: 26542519 DOI: 10.1152/japplphysiol.00547.2015] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/30/2015] [Indexed: 02/06/2023] Open
Abstract
Diabetic patients have an increased risk of foot ulcers, and glycation of collagen may increase tissue stiffness. We hypothesized that the level of glycemic control (glycation) may affect Achilles tendon stiffness, which can influence gait pattern. We therefore investigated the relationship between collagen glycation, Achilles tendon stiffness parameters, and plantar pressure in poorly (n = 22) and well (n = 22) controlled diabetic patients, including healthy age-matched (45-70 yr) controls (n = 11). There were no differences in any of the outcome parameters (collagen cross-linking or tendon stiffness) between patients with well-controlled and poorly controlled diabetes. The overall effect of diabetes was explored by collapsing the diabetes groups (DB) compared with the controls. Skin collagen cross-linking lysylpyridinoline, hydroxylysylpyridinoline (136%, 80%, P < 0.01) and pentosidine concentrations (55%, P < 0.05) were markedly greater in DB. Furthermore, Achilles tendon material stiffness was higher in DB (54%, P < 0.01). Notably, DB also demonstrated higher forefoot/rearfoot peak-plantar-pressure ratio (33%, P < 0.01). Overall, Achilles tendon material stiffness and skin connective tissue cross-linking were greater in diabetic patients compared with controls. The higher foot pressure indicates that material stiffness of tendon and other tissue (e.g., skin and joint capsule) may influence foot gait. The difference in foot pressure distribution may contribute to the development of foot ulcers in diabetic patients.
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Affiliation(s)
- Christian Couppé
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Physical Therapy, Musculoskeletal Rehabilitation Research Unit, Bispebjerg Hospital, Copenhagen, Denmark;
| | - Rene Brüggebusch Svensson
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mads Kongsgaard
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vuokko Kovanen
- Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Jean-Francois Grosset
- CNRS UMR 7338, Biomécanique et Bioingénierie, Université de Technologie de Compiègne, Compiègne, France; Université Paris 13, Sorbonne Paris Cité, UFR Santé Médecine et Biologie Humaine, Paris, France
| | - Ole Snorgaard
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Jesper Bencke
- Gait Analysis Laboratory, Department of Orthopaedics, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jytte Overgaard Larsen
- Department of Neuroscience and Pharmacology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bandholm
- Physical Medicine and Rehabilitation Research-Copenhagen, Department of Physical Therapy, Copenhagen, Denmark; Department of Orthopedic Surgery, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark; Clinical Research Centre, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | | | - Anders Boesen
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ida Carøe Helmark
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Aagaard
- Institute of Sports Science and Clinical Biomechanics, SDU Muscle Research Cluster, University of Southern Denmark, Odense, Denmark
| | - Michael Kjaer
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stig Peter Magnusson
- IOC Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Physical Therapy, Musculoskeletal Rehabilitation Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
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Evranos B, Idilman I, Ipek A, Polat SB, Cakir B, Ersoy R. Real-time sonoelastography and ultrasound evaluation of the Achilles tendon in patients with diabetes with or without foot ulcers: a cross sectional study. J Diabetes Complications 2015; 29:1124-9. [PMID: 26382616 DOI: 10.1016/j.jdiacomp.2015.08.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/04/2015] [Accepted: 08/17/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is an endocrine disease characterized by metabolic abnormalities and long-term complications. The Achilles tendon (AT) plays an important role in foot biomechanics. We aimed to investigate the effect of DM on the Achilles tendon, which may contribute to long-term complications in the foot-ankle complex. METHODS Seventy-eight patients with diabetes, with (35 patients, group I) or without (43 patients, group II) foot ulcers were recruited from the endocrinology clinic. Thirty-three age-, gender-, and BMI-matched healthy individuals were selected as controls. All participants underwent ultrasonography and sonoelastography of their AT in order to evaluate Achilles tendon thickness (ATT) and stiffness (ATS). Each patient was also tested for fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1C) as a measure of diabetes control. Other chronic complications were also evaluated in all patients with diabetes. RESULTS The AT was significantly thicker in group I compared to group II and the controls. HbA1C, FPG, and duration of diabetes were higher in group I. We observed that ATT was positively correlated with neuropathy, retinopathy, nephropathy, peripheral arterial disease and coronary arterial disease in group II while this correlation was not detected in group I. ATS was reduced in group I more than group II and control groups. CONCLUSION Changes in the structure of the AT may precede foot ankle disorders in patients with diabetes. This is the first study that reported the results of sonoelastosonography of AT in patients with diabetes and revealed the correlation between ATT and other chronic complications of diabetes.
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Affiliation(s)
- Berna Evranos
- Yildirim Beyazit University, Ataturk Education and Research Hospital, Endocrinology and Metabolism Department, Ankara, Turkey.
| | - Ilkay Idilman
- Ataturk Education and Research Hospital, Radiology Department, Ankara, Turkey
| | - Ali Ipek
- Ataturk Education and Research Hospital, Radiology Department, Ankara, Turkey
| | - Sefika Burcak Polat
- Yildirim Beyazit University, Ataturk Education and Research Hospital, Endocrinology and Metabolism Department, Ankara, Turkey
| | - Bekir Cakir
- Yildirim Beyazit University, Ataturk Education and Research Hospital, Endocrinology and Metabolism Department, Ankara, Turkey
| | - Reyhan Ersoy
- Yildirim Beyazit University, Ataturk Education and Research Hospital, Endocrinology and Metabolism Department, Ankara, Turkey
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24
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Hubbuch JE, Bennett BW, Dean JC. Proprioceptive feedback contributes to the adaptation toward an economical gait pattern. J Biomech 2015; 48:2925-31. [PMID: 25935689 DOI: 10.1016/j.jbiomech.2015.04.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/04/2015] [Indexed: 11/17/2022]
Abstract
Humans generally prefer gait patterns with a low metabolic cost, but it is unclear how such patterns are chosen. We have previously proposed that humans may use proprioceptive feedback to identify economical movement patterns. The purpose of the present experiments was to investigate the role of plantarflexor proprioception in the adaptation toward an economical gait pattern. To disrupt proprioception in some trials, we applied noisy vibration (randomly varying between 40-120Hz) over the bilateral Achilles tendons while participants stood quietly or walked on a treadmill. For all 10min walking trials, the treadmill surface was initially level before slowly increasing to a 2.5% incline midway through the trial without participant knowledge. During standing posture, noisy vibration increased sway, indicating decreased proprioception accuracy. While walking on a level surface, vibration did not significantly influence stride period or metabolic rate. However, vibration had clear effects for the first 2-3min after the incline increase; vibration caused participants to walk with shorter stride periods, reduced medial gastrocnemius (MG) activity during mid-stance (30-65% stance), and increased MG activity during late-stance (65-100% stance). Over time, these metrics gradually converged toward the gait pattern without vibration. Likely as a result of this delayed adaptation to the new mechanical context, the metabolic rate when walking uphill was significantly higher in the presence of noisy vibration. These results may be explained by the disruption of proprioception preventing rapid identification of muscle activation patterns which allow the muscles to operate under favorable mechanical conditions with low metabolic demand.
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Affiliation(s)
- Jill E Hubbuch
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Blake W Bennett
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA
| | - Jesse C Dean
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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25
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Shi L, Rui YF, Li G, Wang C. Alterations of tendons in diabetes mellitus: what are the current findings? INTERNATIONAL ORTHOPAEDICS 2015; 39:1465-73. [PMID: 25944078 DOI: 10.1007/s00264-015-2775-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/23/2015] [Indexed: 12/13/2022]
Abstract
As a connective tissue, tendon connects the muscle and bone, and plays the key role in the locomotor system. Some previous studies have shown the pathological alternations in diabetic tendons, which might result in the structural and functional changes, and even accelerate the process of diabetic foot. In this review, we examined the current findings of the diabetic tendons in the form of various aspects, and summarized the clinical presentation, imaging, biomechanical, histopathological, cellular and molecular abnormalities in the diabetic tendons. The progress of diabetic tendon damage is complicated and the main hypotheses include the excessive accumulation of AGEs, the altered inflammatory response, neovascularization and insensitive neuropathy. However, the cellular and molecular mechanisms of these alterations are still ambiguous. Tendon stem/progenitor cells (TSPCs) have been discovered to play important roles in both tendon physiology and tendon pathology. Recently, we identified TSPCs from patellar tendons in our well-established diabetic rat model and found impaired tenogenic differentiation potential of these cells. We proposed a new hypothesis that the impaired cell functions of diabetic TSPCs might be the underlying cellular and molecular mechanism of the diabetic tendon alternations. These findings should be helpful to establish a better therapeutic strategy for diabetic tendon repair and regeneration.
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Affiliation(s)
- Liu Shi
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China
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26
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Wukich DK. Diabetes and its negative impact on outcomes in orthopaedic surgery. World J Orthop 2015; 6:331-339. [PMID: 25893176 PMCID: PMC4390895 DOI: 10.5312/wjo.v6.i3.331] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 09/21/2014] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
An estimated 285 million adults (aged 20-79 years) worldwide were diagnosed to have diabetes mellitus (DM) in 2010, and this number is projected to grow to 439 million adults by the year 2030. Orthopaedic surgeons, regardless of their subspecialty interest, will encounter patients with DM during their career since this epidemic involves both developed and emerging countries. Diabetes results in complications affecting multiple organ systems, potentially resulting in adverse outcomes after orthopaedic surgery. The purpose of this review is to discuss the pathophysiology of DM and its potential for impacting orthopaedic surgery patients. Diabetes adversely affects the outcome of all orthopaedic surgery subspecialties including foot and ankle, upper extremity, adult reconstructive, pediatrics, spine surgery and sports medicine. Poorly controlled diabetes negatively impacts bone, soft tissue, ligament and tendon healing. It is the complications of diabetes such as neuropathy, peripheral artery disease, and end stage renal disease which contributes to adverse outcomes. Well controlled diabetic patients without comorbidities have similar outcomes to patients without diabetes. Orthopaedic surgeons should utilize consultants who will assist in inpatient glycemic management as well as optimizing long term glycemic control.
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27
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Boivin GP, Elenes EY, Schultze AK, Chodavarapu H, Hunter SA, Elased KM. Biomechanical properties and histology of db/db diabetic mouse Achilles tendon. Muscles Ligaments Tendons J 2014. [PMID: 25489543 DOI: 10.11138/mltj/2014.4.3.280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Foot ulcers are a severe complication of diabetic patients resulting from nerve and tendon pathologic alterations. In diabetic patients the tendons are thicker, shorter and have increased stiffness. We examined C57BL/KsJ (BKS.Cg-Dock7(m) +/+ Lepr (db) /J) (db/db) mice tendons to determine whether they are an animal model for human diabetic tendon changes. We hypothesized that the Achilles tendons of db/db diabetic mice would be thicker, stiffer, fail at lower loads and stresses, and have degenerative changes compared to control mice. Biomechanical and histologic analyses of the Achilles tendons of 16 week old db/db and control male mice were performed. There was a significant increase in tendon diameter and significant decreases in maximum load, tensile stress, stiffness and elastic modulus in tendons from diabetic mice compared to controls. Mild degenerative and neutrophil infiltration was observed near the tendon insertions on the calcaneous in 25% of db/db mice. In summary, hyper-glycemia and obesity lead to severe changes in db/db mice will be a useful model to examine mechanisms for tendon alterations.
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Affiliation(s)
| | | | | | - Harshita Chodavarapu
- Department of Pharmacology and Toxicology, Wright State University, Dayton, OH USA
| | | | - Khalid M Elased
- Department of Pharmacology and Toxicology, Wright State University, Dayton, OH USA
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Handsaker JC, Brown SJ, Bowling FL, Cooper G, Maganaris CN, Boulton AJM, Reeves ND. Contributory factors to unsteadiness during walking up and down stairs in patients with diabetic peripheral neuropathy. Diabetes Care 2014; 37:3047-53. [PMID: 25315208 DOI: 10.2337/dc14-0955] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although patients with diabetic peripheral neuropathy (DPN) are more likely to fall than age-matched controls, the underlying causative factors are not yet fully understood. This study examines the effects of diabetes and neuropathy on strength generation and muscle activation patterns during walking up and down stairs, with implications for fall risk. RESEARCH DESIGN AND METHODS Sixty-three participants (21 patients with DPN, 21 diabetic controls, and 21 healthy controls) were examined while walking up and down a custom-built staircase. The speed of strength generation at the ankle and knee and muscle activation patterns of the ankle and knee extensor muscles were analyzed. RESULTS Patients with neuropathy displayed significantly slower ankle and knee strength generation than healthy controls during stair ascent and descent (P < 0.05). During ascent, the ankle and knee extensor muscles were activated significantly later by patients with neuropathy and took longer to reach peak activation (P < 0.05). During descent, neuropathic patients activated the ankle extensors significantly earlier, and the ankle and knee extensors took significantly longer to reach peak activation (P < 0.05). CONCLUSIONS Patients with DPN are slower at generating strength at the ankle and knee than control participants during walking up and down stairs. These changes, which are likely caused by altered activations of the extensor muscles, increase the likelihood of instability and may be important contributory factors for the increased risk of falling. Resistance exercise training may be a potential clinical intervention for improving these aspects and thereby potentially reducing fall risk.
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Affiliation(s)
| | | | | | - Glen Cooper
- Manchester Metropolitan University, Manchester, U.K
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29
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The association between physical characteristics of the ankle joint and the mobility performance in elderly people with type 2 diabetes mellitus. Arch Gerontol Geriatr 2014; 59:346-52. [DOI: 10.1016/j.archger.2014.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 05/26/2014] [Accepted: 07/01/2014] [Indexed: 12/25/2022]
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Francia P, Gulisano M, Anichini R, Seghieri G. Diabetic foot and exercise therapy: step by step the role of rigid posture and biomechanics treatment. Curr Diabetes Rev 2014; 10:86-99. [PMID: 24807636 PMCID: PMC5750747 DOI: 10.2174/1573399810666140507112536] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/02/2014] [Accepted: 05/05/2014] [Indexed: 12/16/2022]
Abstract
Lower extremity ulcers represent a serious and costly complication of diabetes mellitus. Many factors contribute to the development of diabetic foot. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute in turn to the growth of additional risk factors such as limited joint mobility, muscular alterations and foot deformities. Moreover, a deficit of balance, posture and biomechanics can be present, in particular in patients at high risk for ulceration. The result of this process may be the development of a vicious cycle which leads to abnormal distribution of the foot's plantar pressures in static and dynamic postural conditions. This review shows that some of these risk factors significantly improve after a few weeks of exercise therapy (ET) intervention. Accordingly it has been suggested that ET can be an important weapon in the prevention of foot ulcer. The aim of ET can relate to one or more alterations typically found in diabetic patients, although greater attention should be paid to the evaluation and possible correction of body balance, rigid posture and biomechanics. Some of the most important limitations of ET are difficult access to therapy, patient compliance and the transitoriness of the results if the training stops. Many proposals have been made to overcome such limitations. In particular, it is important that specialized centers offer the opportunity to participate in ET and during the treatment the team should work to change the patient's lifestyle by improving the execution of appropriate daily physical activity.
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Affiliation(s)
| | | | | | - Giuseppe Seghieri
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3 - 50134 Florence, Italy.
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31
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Wellinghoff MA, Bunchman AM, Dean JC. Gradual mechanics-dependent adaptation of medial gastrocnemius activity during human walking. J Neurophysiol 2014; 111:1120-31. [PMID: 24335207 PMCID: PMC3949234 DOI: 10.1152/jn.00251.2013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 12/08/2013] [Indexed: 01/13/2023] Open
Abstract
While performing a simple bouncing task, humans modify their preferred movement period and pattern of plantarflexor activity in response to changes in system mechanics. Over time, the preferred movement pattern gradually adapts toward the resonant frequency. The purpose of the present experiments was to determine whether humans undergo a similar process of gradually adapting their stride period and plantarflexor activity after a change in mechanical demand while walking. Participants walked on a treadmill while we measured stride period and plantarflexor activity (medial gastrocnemius and soleus). Plantarflexor activity during stance was divided into a storage phase (30-65% stance) and a return phase (65-100% stance) based on when the Achilles tendon has previously been shown to store and return mechanical energy. Participants walked either on constant inclines (0%, 1%, 5%, 9%) or on a variable incline (0-1%) for which they were unaware of the incline changes. For variable-incline trials, participants walked under both single-task and dual-task conditions in order to vary the cognitive load. Both stride period and plantarflexor activity increased at steeper inclines. During single-task walking, small changes in incline were followed by gradual adaptation of storage-phase medial gastrocnemius activity. However, this adaptation was not present during dual-task walking, indicating some level of cognitive involvement. The observed adaptation may be the result of using afferent feedback in order to optimize the contractile conditions of the plantarflexors during the stance phase. Such adaptation could serve to improve metabolic economy but may be limited in clinical populations with disrupted proprioception.
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Affiliation(s)
- Molly A Wellinghoff
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; and
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32
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Ko M, Chiu YP, Hung YJ. Dynamic Postural Control in Older People With Diabetes During Gait Initiation. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2013. [DOI: 10.3109/02703181.2013.823637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wolfson TS, Hamula MJ, Jazrawi LM. Impact of diabetes mellitus on surgical outcomes in sports medicine. PHYSICIAN SPORTSMED 2013; 41:64-77. [PMID: 24231598 DOI: 10.3810/psm.2013.11.2037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.
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Affiliation(s)
- Theodore S Wolfson
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, NY
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Deschamps K, Matricali GA, Roosen P, Nobels F, Tits J, Desloovere K, Bruyninckx H, Flour M, Deleu PA, Verhoeven W, Staes F. Comparison of foot segmental mobility and coupling during gait between patients with diabetes mellitus with and without neuropathy and adults without diabetes. Clin Biomech (Bristol, Avon) 2013; 28:813-9. [PMID: 23829980 DOI: 10.1016/j.clinbiomech.2013.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 06/15/2013] [Accepted: 06/17/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reduction in foot mobility has been identified as a key factor of altered foot biomechanics in individuals with diabetes mellitus. This study aimed at comparing in vivo segmental foot kinematics and coupling in patients with diabetes with and without neuropathy to control adults. METHODS Foot mobility of 13 diabetic patients with neuropathy, 13 diabetic patients without neuropathy and 13 non-diabetic persons was measured using an integrated measurement set-up including a plantar pressure platform and 3D motion analysis system. In this age-, sex- and walking speed matched comparative study; differences in range of motion quantified with the Rizzoli multisegment foot model throughout different phases of the gait cycle were analysed using one-way repeated measures analysis of variance (ANOVA). Coupling was assessed with cross-correlation techniques. FINDINGS Both cohorts with diabetes showed significantly lower motion values as compared to the control group. Transverse and sagittal plane motion was predominantly affected with often lower range of motion values found in the group with neuropathy compared to the diabetes group without neuropathy. Most significant changes were observed during propulsion (both diabetic groups) and swing phase (predominantly diabetic neuropathic group). A trend of lower cross-correlations between segments was observed in the cohorts with diabetes. INTERPRETATION Our findings suggest an alteration in segmental kinematics and coupling during walking in diabetic patients with and without neuropathy. Future studies should integrate other biomechanical measurements as it is believed to provide additional insight into neural and mechanical deficits associated to the foot in diabetes.
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Affiliation(s)
- K Deschamps
- KU Leuven, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Group, Weligerveld 1, 3212 Pellenberg, Belgium; KU Leuven, Laboratory for Clinical Motion Analysis, University Hospital Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium; KU Leuven, Multidisciplinary Diabetic Foot Clinic, University Hospitals Leuven, Weligerveld 1, 3212 Pellenberg, Belgium; Institut D'Enseignement Supérieur Parnasse Deux-Alice, Division of Podiatry, Bruxelles, Weligerveld 1, 3212 Pellenberg, Belgium.
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35
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Cronin NJ, Lichtwark G. The use of ultrasound to study muscle-tendon function in human posture and locomotion. Gait Posture 2013; 37:305-12. [PMID: 22910172 DOI: 10.1016/j.gaitpost.2012.07.024] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 02/02/2023]
Abstract
Analysis of human movement has traditionally relied on measures such as kinematics, kinetics and electromyography. These measures provide valuable information about movement performance and make it possible to draw inferences about muscle and tendon function. Musculoskeletal models are also used frequently to examine the relationship between joint kinematics and muscle-tendon behaviour, and have provided important insights into both healthy and clinical gait. However, muscles interact with compliant tendons during movement, which complicates interpretation of muscle and tendon function based on external measures such as joint kinematics. Accordingly, methods have been developed that enable muscle and tendinous tissues to be imaged in real-time. Ultrasound is among the most popular methods used for this purpose, and has been applied extensively to the study of in vivo muscle and tendon function in a range of human populations and movement contexts. There is a growing body of literature that proposes different measures of muscle and/or tendon function, and these results need to be discussed in light of the technical differences between the measurement techniques. In this review we first outline the various uses of ultrasound to examine human muscle and tendon function, and then summarise ultrasound-based research specifically during locomotion and postural conditions. We then describe some of the many technical issues associated with this method. Methods of data analysis are introduced, including novel automated techniques that improve the efficiency of the analysis process. Finally, possible future directions in musculoskeletal ultrasound research are discussed.
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Affiliation(s)
- Neil J Cronin
- Neuromuscular Research Centre, Department of Biology of Physical Activity, University of Jyväskylä, Finland.
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36
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Abate M, Schiavone C, Salini V, Andia I. Occurrence of tendon pathologies in metabolic disorders. Rheumatology (Oxford) 2013; 52:599-608. [PMID: 23315787 DOI: 10.1093/rheumatology/kes395] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This article reviews the pathogenetic role of metabolic disorders, which are of paramount relevance to the progression of tendon damage. In diabetes, the prevalence of rheumatological diseases is high, mainly because of the deleterious effects of advanced glycation end products that deteriorate the biological and mechanical functions of tendons and ligaments. In heterozygous familial hypercholesterolaemia, most patients develop Achilles xanthomatosis, a marker of high risk for cardiovascular disease caused by cholesterol deposition in the tendons. Tendon degeneration has also been observed in non-familial hypercholesterolaemia. Monosodium urate crystal deposition in soft tissues is a hallmark of chronic gouty arthritis. In this group of diseases, the mobilization of cholesterol and uric acid crystals is presumably followed by low-grade inflammation, which is responsible for tendon degeneration. Adiposity may contribute to tendon disorders via two different mechanisms: increased weight on the load-bearing tendons and systemic dysmetabolic factors that trigger subclinical persistent inflammation. Finally, tendon abnormalities have been observed in some rare congenital metabolism disorders such as alkaptonuria.
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Affiliation(s)
- Michele Abate
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Chieti Scalo (CH), Italy.
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Cronin NJ, Carty CP, Barrett RS, Lichtwark G. Automatic tracking of medial gastrocnemius fascicle length during human locomotion. J Appl Physiol (1985) 2011; 111:1491-6. [PMID: 21836045 DOI: 10.1152/japplphysiol.00530.2011] [Citation(s) in RCA: 152] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
During human locomotion lower extremity muscle-tendon units undergo cyclic length changes that were previously assumed to be representative of muscle fascicle length changes. Measurements in cats and humans have since revealed that muscle fascicle length changes can be uncoupled from those of the muscle-tendon unit. Ultrasonography is frequently used to estimate fascicle length changes during human locomotion. Fascicle length analysis requires time consuming manual methods that are prone to human error and experimenter bias. To bypass these limitations, we have developed an automatic fascicle tracking method based on the Lucas-Kanade optical flow algorithm with an affine optic flow extension. The aims of this study were to compare gastrocnemius fascicle length changes during locomotion using the automated and manual approaches and to determine the repeatability of the automated approach. Ultrasound was used to examine gastrocnemius fascicle lengths in eight participants walking at 4, 5, 6, and 7 km/h and jogging at 7 km/h on a treadmill. Ground reaction forces and three dimensional kinematics were recorded simultaneously. The level of agreement between methods and the repeatability of the automated method were quantified using the coefficient of multiple correlation (CMC). Regardless of speed, the level of agreement between methods was high, with overall CMC values of 0.90 ± 0.09 (95% CI: 0.86-0.95). Repeatability of the algorithm was also high, with an overall CMC of 0.88 ± 0.08 (95% CI: 0.79-0.96). The automated fascicle tracking method presented here is a robust, reliable, and time-efficient alternative to the manual analysis of muscle fascicle length during gait.
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Affiliation(s)
- Neil J Cronin
- Musculoskeletal Research Program, Griffith Health Institute, Griffith University, Queensland, Australia.
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