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Stewart C, King MG, Kemp JL, Mentiplay BF, O'Brien MJ, Perraton Z, Lawrenson PR, Semciw AI. Hip muscle activity in people with hip-related pain compared to asymptomatic controls: A systematic review. J Electromyogr Kinesiol 2023; 71:102784. [PMID: 37331133 DOI: 10.1016/j.jelekin.2023.102784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 05/02/2023] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Altered hip and thigh muscle activity have been observed across a spectrum of articular hip pathologies, including hip osteoarthritis, femoroacetabular impingement syndrome, and labral pathology. No systematic reviews have examined muscle activity associated with hip pathology and hip-related pain across the life span. A greater understanding of impairments in hip and thigh muscle activity during functional tasks may assist in the development of targeted treatment strategies. METHODS We conducted a systematic review using the PRISMA guidelines. A literature search was performed in five databases (MEDLINE, CINAHL, EMBASE, Sports Discuss, and PsychINFO). Studies were included that (i) investigated people with hip-related pain (femoroacetabular impingement syndrome, labral tears) or hip osteoarthritis; and (ii) reported on muscle activity using electromyography of hip and thigh muscles during functional tasks such as walking, stepping, squatting, or lunging. Two independent reviewers performed data extraction and assessed risk of bias using a modified version of the Downs and Black checklist. RESULTS Non-pooled data demonstrated a limited level of evidence. Overall, differences in muscle activity appeared to be more prevalent in people with more advanced hip pathology. CONCLUSIONS We found that impairments in muscle activity in those with intra-articular hip pathology measured using electromyography were variable but appeared to be greater in severe hip pathology (e.g., hip OA).
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Affiliation(s)
- Christopher Stewart
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia
| | - Matthew G King
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia
| | - Joanne L Kemp
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia; La Trobe Sports and Exercise Medicine Research Center, La Trobe University
| | - Benjamin F Mentiplay
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia
| | - Michael Jm O'Brien
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia
| | - Zuzana Perraton
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia
| | - Peter R Lawrenson
- University of Queensland, School of Health and Rehabilitation Sciences, Australia
| | - Adam I Semciw
- La Trobe University, School of Allied Health, Human Services, and Sport, Australia.
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Makani A, Shirazi-Adl SA, Ghezelbash F. Computational biomechanics of human knee joint in stair ascent: Muscle-ligament-contact forces and comparison with level walking. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3646. [PMID: 36054682 DOI: 10.1002/cnm.3646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/28/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
About a third of knee joint disorders originate from the patellofemoral (PF) site that makes stair ascent a difficult activity for patients. A detailed finite element model of the knee joint is coupled to a lower extremity musculoskeletal model to simulate the stance phase of stair ascent. It is driven by the mean of measurements on the hip-knee-ankle moments-angles as well as ground reaction forces reported in healthy individuals. Predicted muscle activities compare well to the recorded electromyography data. Peak forces in quadriceps (3.87 BW, body weight, at 20% instance in our 607 N subject), medial hamstrings (0.77 BW at 20%), and gastrocnemii (1.21 BW at 80%) are estimated. Due to much greater flexion angles-moments in the first half of stance, large PF contact forces (peak of 3.1 BW at 20% stance) and stresses (peak of 4.83 MPa at 20% stance) are estimated that exceed their peaks in level walking by fourfold and twofold, respectively. Compared with level walking, ACL forces diminish in the first half of stance but substantially increase later in the second half (peak of 0.76 BW at 75% stance). Under nearly similar contact forces at 20% of stance, the contact stress on the tibiofemoral (TF) medial plateau reaches a peak (9.68 MPa) twice that on the PF joint suggesting the vulnerability of both joints. Compared with walking, stair ascent increases peak ACL force and both peak TF and PF contact stresses. Reductions in the knee flexion moment and/or angle appear as a viable strategy to mitigate internal loads and pain.
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Affiliation(s)
- Amirhossein Makani
- Department of Mechanical Engineering, Polytechnique Montréal, Montreal, Québec, Canada
| | - Saeed A Shirazi-Adl
- Department of Mechanical Engineering, Polytechnique Montréal, Montreal, Québec, Canada
| | - Farshid Ghezelbash
- Department of Mechanical Engineering, Polytechnique Montréal, Montreal, Québec, Canada
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Neuromuscular Consequences of Lumbopelvic Dysfunction: Research and Clinical Perspectives. J Sport Rehabil 2022; 31:742-748. [PMID: 35894966 DOI: 10.1123/jsr.2021-0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 05/10/2022] [Accepted: 05/24/2022] [Indexed: 11/18/2022]
Abstract
Injuries involving the lumbopelvic region (ie, lumbar spine, pelvis, hip) are common across the lifespan and include pathologies such as low back pain, femoroacetabular impingement syndrome, labrum tear, and osteoarthritis. Joint injury is known to result in an arthrogenic muscle response which contributes to muscle weakness and altered movement patterns. The purpose of this manuscript is to summarize the arthrogenic muscle response that occurs across lumbopelvic region pathologies, identify methods to quantify muscle function, and propose suggestions for future research. While each lumbopelvic region pathology is unique, there are a few common impairments and a relative consistent arthrogenic muscle response that occurs across the region. Hip muscle weakness and hip joint range of motion limitations occur with both lumbar spine and hip pathologies, and individuals with low back pain are known to demonstrate inhibition of the transversus abdominis and multifidus. Assessment of muscle inhibition is often limited to research laboratory settings, but dynamometers, ultrasound imaging, and electromyography offer clinical capacity to quantify muscle function and inform treatment pathways. Future studies should systematically determine the arthrogenic muscle response across multiple muscle groups and the timeline for changes in muscle function and determine whether disinhibitory modalities improve functional outcomes beyond traditional treatment approaches.
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Jochimsen K, Brown-Taylor L, Perry J, Glaws K, Lewis C, Ryan J, Di Stasi S. Biomechanical measures of clinician-defined unsteadiness during a forward stepdown task in individuals post-arthroscopy for femoroacetabular impingement syndrome. Clin Biomech (Bristol, Avon) 2022; 93:105586. [PMID: 35219043 PMCID: PMC9520757 DOI: 10.1016/j.clinbiomech.2022.105586] [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: 04/12/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with femoroacetabular impingement syndrome can present with aberrant movement patterns including unsteady balance. Balance training is included in rehabilitation after hip arthroscopy and may improve quality of movement; however, specific biomechanical measures associated with clinician-defined balance impairments are unknown. We aimed to understand these associations as they may inform targeted rehabilitative interventions. METHODS The forward stepdown is a clinical test used to evaluate movement quality, including balance. 23 individuals at least one-year post-arthroscopy for femoroacetabular impingement syndrome and 15 healthy comparisons performed the forward stepdown, recorded by 3-dimensional motion capture and 2-dimensional video. Three physical therapists graded the 2-dimensional video for steadiness. Two-way analyses of variance were used to evaluate the interaction of group (post-arthroscopy/healthy comparison) by steadiness (steady/unsteady), for center of pressure medial-lateral excursion, center of pressure path length, and lateral trunk, pelvis, and lower extremity joint excursions. FINDINGS Six (26.1%) participants post-arthroscopy and five (33.3%) healthy comparisons were categorized as unsteady. The odds of being categorized as unsteady were not greater for participants post-arthroscopy (P = 0.72). There were no significant interactions; however, participants with clinician-defined unsteady balance, regardless of group, had significantly greater frontal plane trunk excursion, greater hip excursion, and greater center of pressure path length than those with steady balance (P ≤ 0.006). INTERPRETATION The odds of being categorized as unsteady were not greater for individuals post-arthroscopy for femoroacetabular impingement syndrome. Clinician-defined unsteadiness was associated with greater frontal plane trunk and hip motion which may be rehabilitation targets to improve balance during a dynamic single-leg task.
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Affiliation(s)
- K.N. Jochimsen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, United States,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, 453 W. 10th Avenue, Columbus, OH 43210, United States,Corresponding author at: Division of Athletic Training, School of Medicine, West Virginia University, 1 Medical Center Drive, 8501B Health Sciences Center South, Morgantown, WV 26506-9225, United States. (K.N. Jochimsen)
| | - L. Brown-Taylor
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, United States,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, 453 W. 10th Avenue, Columbus, OH 43210, United States,Health and Rehabilitation Sciences Doctoral Program, School of Health and Rehabilitation Sciences, The Ohio State University, 453 W. 10th Avenue, Columbus, OH 43210, United States
| | - J. Perry
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, United States
| | - K. Glaws
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, United States
| | - C.L. Lewis
- Department of Physical Therapy and Athletic Training, Boston University, 635 Commonwealth Avenue, Boston, MA 02215, United States
| | - J. Ryan
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, United States,Department of Orthopaedics, The Ohio State University Wexner Medical Center, 370 W. 9th Avenue, Columbus, OH 43210, United States
| | - S. Di Stasi
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH 43202, United States,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, 453 W. 10th Avenue, Columbus, OH 43210, United States
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Dynamic Assessment of Femoroacetabular Impingement Syndrome Hips. Arthroscopy 2022; 38:404-416.e3. [PMID: 34126220 DOI: 10.1016/j.arthro.2021.05.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/18/2021] [Accepted: 05/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of our study was to compare lower extremity rotational kinematics and kinetics (angles, torques, and powers) and hip muscle electromyography (EMG) activity between cam-type femoroacetabular impingement syndrome (FAIS) and age- and sex-matched controls during walking, fast walking, stair ascent, stair descent, and sit-to-stand. METHODS This study included 10 males with unilateral FAIS and 10 control males with no FAIS. We measured kinematics, kinetics, and electromyographic signals during stair ascent/descent, sit-to-stand, self-selected walk, and fast walk. Peak signal differences between groups were compared with independent t-tests with statistical significance when P < .05. RESULTS FAIS hips showed significant differences compared to controls, including increased hip flexion during walking (+4.9°, P = .048) and stair ascent (+7.8°, P =.003); diminished trunk rotation during stair ascent (-3.4°; P = .015), increased knee flexion during self-selected walking (+5.1°, P = .009), stair ascent (+7.4°, P = .001), and descent (+5.3°, P = .038); and increased knee valgus during fast walking (+4.7°, P = .038). gMed and MedHam showed significantly decreased activation in FAIS during walking (gMed: -12.9%, P = .002; MedHam: -7.4%, P = .028) and stair ascent (gMed: -16.7%, P = .036; MedHam: -13.0%, P = .041); decreased gMed activation during sit-to-stand (-8.8%, P = .004) and decreased MedHam activation during stair descent (-8.0%, P = .039). CONCLUSIONS Three-dimensional motion analysis and EMG evaluation of functional kinematics and kinetics in subjects with symptomatic unilateral cam-type FAIS across a spectrum of provocative tasks demonstrated significant differences compared to controls in hip flexion, trunk rotation, knee flexion, and valgus. FAIS hips had significantly decreased gMed and MedHam activity. These findings may explain altered torso-pelvic, hip, and knee mechanics in FAIS patients and suggest that evaluation of FAIS should include the patient's hip, knee, and torso-pelvic relationships and muscle function. CLINICAL RELEVANCE The clinical and functional manifestation of FAIS hip pathomechanics is not entirely understood, and previous literature to date has not clearly described the alterations in gait and functional movements seen in patients with cam-type FAIS. The current study used 3D motion analysis and EMG evaluation of functional kinematics and kinetics to identify a number of differences between FAIS and control hips, which help us better understand the lower extremity kinematics and kinetics and muscle activation in FAIS.
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Quinn L, Riley N, Tyrell CM, Judd DL, Gill-Body KM, Hedman LD, Packel A, Brown DA, Nabar N, Scheets P. A Framework for Movement Analysis of Tasks: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force. Phys Ther 2021; 101:6307338. [PMID: 34160044 DOI: 10.1093/ptj/pzab154] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/11/2021] [Accepted: 05/30/2021] [Indexed: 11/12/2022]
Abstract
The American Physical Therapy Association's Vision Statement of 2013 asserts that physical therapists optimize movement in order to improve the human experience. In accordance with this vision, physical therapists strive to be recognized as experts in movement analysis. However, there continues to be no accepted method to conduct movement analysis, nor an agreement of key terminology to describe movement observations. As a result, the Academy of Neurologic Physical Therapy organized a task force that was charged with advancing the state of practice with respect to these issues, including the development of a proposed method for movement analysis of tasks. This paper presents the work of the Task Force, which includes (1) development of a method for conducting movement analysis within the context of the movement continuum during 6 core tasks (sitting, sit to stand, standing, walking, step up/down, and reach/grasp/manipulate); (2) glossary of movement constructs that can provide a common language for movement analysis across a range of tasks: symmetry, speed, amplitude, alignment, verticality, stability, smoothness, sequencing, timing, accuracy, and symptom provocation; and (3) recommendations for task and environmental variations that can be systematically applied. The expectation is that this systematic framework and accompanying terminology will be easily adapted to additional patient or client-specific tasks, contribute to development of movement system diagnostic labels, and ultimately improve consistency across patient/client examination, evaluation, and intervention for the physical therapy profession. Next steps should include validation of this framework across patient/client groups and settings.
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Affiliation(s)
- Lori Quinn
- Dept of Biobehavioral Sciences, Teachers College, Columbia University, New York, New York, USA
| | - Nora Riley
- Physical Therapy Department, St. Ambrose University, Davenport, Iowa, USA
| | - Christine M Tyrell
- Department of Physical Therapy, College of Rehabilitation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dana L Judd
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Lois D Hedman
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - David A Brown
- School of Health Professions, University of Texas Medical Branch, Galveston, Texas, USA
| | - Nikita Nabar
- Baylor Scott and White Inpatient Rehabilitation, Lakeway, Texas, USA
| | - Patricia Scheets
- Infinity Rehab, Quality & Clinical Outcomes, Wilsonville, Oregon, USA
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Brown-Taylor L, Pendley C, Glaws K, Vasileff WK, Ryan J, Harris-Hayes M, Di Stasi SL. Associations Between Movement Impairments and Function, Treatment Recommendations, and Treatment Plans for People With Femoroacetabular Impingement Syndrome. Phys Ther 2021; 101:pzab157. [PMID: 34555167 PMCID: PMC8459885 DOI: 10.1093/ptj/pzab157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/18/2021] [Accepted: 05/06/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The purpose of this study was to describe movement impairments for persons with femoroacetabular impingement syndrome and their association with function, treatment recommendations, and treatment plans. METHODS This report is a secondary, observational analysis of a clinical trial dataset in which participants received an interdisciplinary evaluation from a surgeon and physical therapist. The therapist documented frontal and sagittal plane movement impairments across 6 functional tasks. Associations between number of impairments in each plane and function (33-item International Hip Outcome Tool [iHOT33]) were evaluated using Pearson or Spearman correlations. Joint provider recommendations (physical therapist and surgeon) and participant-reported treatment plans were dichotomized based on the inclusion of physical therapy or not. Logistic regressions were used to examine the effects of (1) iHOT33, total movement impairments, and previous physical therapist treatment on joint provider recommendation and (2) these same variables along with joint provider recommendation on participant treatment plan; prevalence ratios and 95% CIs were reported for significant contributors. RESULTS Thirty-nine participants demonstrated an average iHOT33 of 35.0 (SD = 19.5) and presented with a median 5 frontal and 3 sagittal plane impairments. More frontal plane impairments were associated with worse iHOT33 scores. Twenty-seven participants received a joint provider recommendation that included physical therapy; no significant contributors to these recommendations were identified. Twenty-four of the 27 participants with a physical therapist recommendation included physical therapy in their treatment plan. Two additional participants did not receive a physical therapist recommendation but included physical therapy in their plan. Joint provider recommendation was the only significant contributor to the participant-reported plan (prevalence ratio = 7.06; 95% CI = 3.25-7.97). CONCLUSION Persons with femoroacetabular impingement syndrome displayed clinically observable movement impairments that were associated with worse function. Joint provider recommendations strongly influenced participants' treatment plans to pursue physical therapy. IMPACT Physical therapists contribute new information to surgical examinations regarding movement. Joint recommendations from the physical therapist and the surgeon can influence patients' decisions to pursue physical therapy.
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Affiliation(s)
- Lindsey Brown-Taylor
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs, Salt Lake City, Utah, USA
| | - Chase Pendley
- Registered Physical Therapist Inc., Sandy, Utah, USA
| | - Kathryn Glaws
- University of Colorado Sports Medicine and Performance Center, Aurora, Colorado, USA
| | - W Kelton Vasileff
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - John Ryan
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Marcie Harris-Hayes
- Program in Physical Therapy and Department of Orthopaedic Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Stephanie L Di Stasi
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
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Liu Y, Yoo WG. Effects of lower trunk movement in flat-back syndrome during stair climbing: A technical note. Technol Health Care 2021; 30:483-489. [PMID: 34024794 DOI: 10.3233/thc-202668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study investigated the differences in trunk sway during stair climbing between people with normal spinal alignment and people with flat-back syndrome. METHODS Twelve male volunteers with flat-back syndrome (global angle < 20 degrees) and 12 male volunteers with normal spinal alignment (global angle between 20 degrees and 30 degrees) were enrolled. An accelerator was attached to the third lumbar spine and the sway of each participant's trunk was measured during stair climbing. RESULT Participants with flat-back syndrome showed significant differences in vector, anteroposterior sway, and vertical sway of the trunk during stair climbing (p< 0.05). However, mediolateral sway of the trunk and gait time did not significantly differ between groups (p> 0.05). CONCLUSION Our findings can be used as baseline data for prevention of back pain. Furthermore, increased trunk sway can cause increased energy usage, leading to inefficient gait. Further research is needed to prevent this problem.
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Wang JP, Wang SH, Wang YQ, Hu H, Yu JW, Zhao X, Liu JL, Chen X, Li Y. A data process of human knee joint kinematics obtained by motion-capture measurement. BMC Med Inform Decis Mak 2021; 21:121. [PMID: 33832470 PMCID: PMC8028155 DOI: 10.1186/s12911-021-01483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The motion capture has been used as the usual method for measuring movement parameters of human, and most of the measuring data are obtained by partial manual process based on commercial software. An automatic kinematics data process was developed by programming on MATLAB software in this paper. METHODS The motion capture measurement of healthy volunteers was carried out and the MATLAB program was used for data process. Firstly, the coordinate data of markers and anatomical points on human lower limb measured by motion capture system were read and repaired through the usual and the patch program. Meantime, the local coordinate systems of human femur and tibia were established with anatomical points. Then flexion/extension, abduction/adduction and internal/external rotation of human knee tibiofemoral joint were obtained by special coordinate transformation program. RESULTS Using the above methods, motion capture measurements and batch data processing were carried out on squatting and climbing stairs of 29 healthy volunteers. And the motion characteristics (flexion/extension, internal/external rotation and adduction/abduction) of the knee joint were obtained. For example, the maximum internal/external rotation in squatting and climbing stairs were respectively was 30.5 degrees and 14 degrees, etc. Meantime, the results of this paper also were respectively compared with the results processed by other research methods, and the results were basically consistent, thus the reliability of our research method was verified. After calibration processing, the compiled MATLAB program of this paper can directly be used for efficient batch processing and avoiding manual modeling one by one. CONCLUSION A novel Patch Program of this paper has been developed, which can make reasonable compensation for missing and noise signals to obtain more complete motion data. At the same time, a universal data processing program has also been developed for obtaining the relative movement of various components of the human body, and the program can be modified for detail special analysis. These motion capture technologies can be used to judge whether the human body functions are abnormal, provide a reference for rehabilitation treatment and design of rehabilitation equipment, and evaluate the effectiveness before and after surgery.
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Affiliation(s)
- Jian-Ping Wang
- School of Mechanical and Power Engineering, Henan Polytechnic University, Jiaozuo, 454000, China
| | - Shi-Hua Wang
- School of Mechanical and Power Engineering, Henan Polytechnic University, Jiaozuo, 454000, China
| | - Yan-Qing Wang
- School of Medical Technology, Medical University, Qiqihar, 161006, Heilongjiang Province, China
| | - Hai Hu
- Shanghai Sixth People's Hospital, Shanghai, 200233, China
| | - Jin-Wei Yu
- The First Affiliated Hospital of Henan Polytechnic University, Jiaozuo, 454000, Henan Province, China
| | - Xuan Zhao
- School of Mechanical and Power Engineering, Henan Polytechnic University, Jiaozuo, 454000, China
| | - Jin-Lai Liu
- The First Affiliated Hospital of Henan Polytechnic University, Jiaozuo, 454000, Henan Province, China
| | - Xu Chen
- The First Affiliated Hospital of Henan Polytechnic University, Jiaozuo, 454000, Henan Province, China.
| | - Yu Li
- School of Mechanical and Power Engineering, Henan Polytechnic University, Jiaozuo, 454000, China.
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Biomechanics during cross-body lunging in individuals with and without painful cam and/or pincer morphology. Clin Biomech (Bristol, Avon) 2020; 76:105030. [PMID: 32416407 DOI: 10.1016/j.clinbiomech.2020.105030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/16/2019] [Accepted: 05/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoroacetabular impingement is a patho-mechanical hip condition that can lead to restrictions in hip motion, particularly in end-range hip flexion, adduction and/or internal rotation. Radiographic evidence of femoroacetabular impingement - cam and/or pincer morphology - is prevalent in the general and athletic populations. There is, however, a lack of studies that have analyzed the performance of sport-specific movements in people possessing these morphologies. Therefore, the purpose of this study was to compare cross-body lunge biomechanics between individuals with and without painful cam and/or pincer morphology. METHODS This was an exploratory, cross-sectional study where nine participants with cam and/or pincer morphology and symptoms, thirteen participants with asymptomatic cam and/or pincer morphology, and eleven pain-free controls performed the cross-body lunge during a single session. Trunk, pelvis, hip, knee and ankle kinematics, as well as hip, knee and ankle kinetics and vertical ground reaction forces were examined. FINDINGS Overall, the groups performed the movement similarly, with most variables statistically similar between groups. However, pelvis sagittal plane excursion throughout the entire cross-body lunge was significantly larger in those with cam and/or pincer morphology and symptoms compared to those with asymptomatic cam and/or pincer morphology (P = .046, effect size = 0.98). INTERPRETATION The results of this study show that cross-body lunge performance is similar across individuals with and without painful cam and/or pincer morphology. However, future research should aim to better understand pelvis biomechanics during sporting activities, as pelvis sagittal plane excursion may have important implications in rehabilitation and sport performance.
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Cannon J, Weber AE, Park S, Mayer EN, Powers CM. Pathomechanics Underlying Femoroacetabular Impingement Syndrome: Theoretical Framework to Inform Clinical Practice. Phys Ther 2020; 100:788-797. [PMID: 31899497 DOI: 10.1093/ptj/pzz189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/16/2019] [Accepted: 10/20/2019] [Indexed: 02/06/2023]
Abstract
Over the last decade, there has been a marked increase in attention to, and interest in, femoroacetabular impingement syndrome (FAIS). Despite continued efforts by researchers and clinicians, the development, progression, and appropriate treatment of FAIS remains unclear. While research across various disciplines has provided informative work in various areas related to FAIS, the underlying pathomechanics, time history, and interaction between known risk factors and symptoms remain poorly understood. The purpose of this perspective is to propose a theoretical framework that describes a potential pathway for the development and progression of FAIS. This paper aims to integrate relevant knowledge and understanding from the growing literature related to FAIS to provide a perspective that can inform future research and intervention efforts.
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Affiliation(s)
- Jordan Cannon
- Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | - Alexander E Weber
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California
| | - Seol Park
- Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | - Erik N Mayer
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California
| | - Christopher M Powers
- Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 East Alcazar St, CHP-155, Los Angeles, CA (USA)
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Lower limb muscle activities and gain in balancing ability following two types of stair gait intervention in adult post-chronic stroke patients: A preliminary, randomized-controlled study. Turk J Phys Med Rehabil 2020; 66:17-23. [PMID: 32318670 DOI: 10.5606/tftrd.2020.3335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/23/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to compare the changes in lower limb muscle activities after stair ascending and descending training at two different heights of stairs in patients with chronic stroke and to suggest a stair height which is more effective in improving the strength and balancing ability of these patients. Patients and methods Between November 2016 and February 2017, a total of 20 patients (14 males, 6 females; mean age 56 years; range, 52 to 61 years) with hemiparesis were included in this randomized-controlled study. The patients were randomly assigned to the 10- or 15-cm stair height group (10- and 15-cm groups, respectively; n=10 in each). Both groups received comprehensive rehabilitation therapy and additionally performed stair gait training for 30 min four times per week for a total of six weeks. Balancing abilities and the activities of the paralyzed lower limb's rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius during stair ascending were measured before and after the stair gait training. Results During stair ascent, the 15-cm group showed significantly greater muscle activities of the rectus femoris, biceps femoris, and tibialis anterior than the 10-cm group (p<0.001, η2=0.115; p=0.001, η2=0.022; and p=0.001, η2=0.036, respectively). Conclusion Our study results suggest that ascending stairs with 15-cm step height results in a greater muscle activity than with a 10-cm step height.
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Hip Biomechanics During a Single-Leg Squat: 5 Key Differences Between People With Femoroacetabular Impingement Syndrome and Those Without Hip Pain. J Orthop Sports Phys Ther 2019; 49:908-916. [PMID: 31337265 DOI: 10.2519/jospt.2019.8356] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The hip joint biomechanics of people with femoroacetabular impingement (FAI) syndrome are different from those of healthy people during a double-leg squat. However, information on biomechanics during a single-leg squat is limited. OBJECTIVES To compare hip joint biomechanics between people with FAI syndrome and people without hip pain during double-leg and single-leg squats. METHODS Fourteen people with FAI syndrome (cam, n = 7; pincer, n = 1; mixed, n = 6) and 14 people without hip pain participated in this cross-sectional, case-control, laboratory-based study. Three-dimensional biomechanics data were collected while all participants performed a double-leg and a single-leg squat. Two-way mixed-model analyses of variance were used to assess group-by-task interactions for hip joint angles, thigh and pelvis segment angles, hip joint internal moments, and squat performance variables. Post hoc analyses for all variables with a significant group-by-task interaction were performed to identify between-group differences for each task. RESULTS There were significant group-by-task interactions for peak hip joint (P = .014, η2 = 0.211) and thigh segment (P = .009, η2 = 0.233) adduction angles, and for peak hip joint abduction (P = .002, η2 = 0.308) and extension (P = .016, η2 = 0.203) internal moments. There were no significant group-by-task interactions for squat performance variables. CONCLUSION Biomechanical differences at the hip between people with FAI syndrome and those without hip pain were exaggerated during a single-leg squat compared to a double-leg squat task. LEVEL OF EVIDENCE Diagnosis, level 4. J Orthop Sports Phys Ther 2019;49(12):908-916. Epub 23 Jul 2019. doi:10.2519/jospt.2019.8356.
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Bagwell JJ, Powers CM. Persons with femoroacetabular impingement syndrome exhibit altered pelvifemoral coordination during weightbearing and non-weightbearing tasks. Clin Biomech (Bristol, Avon) 2019; 65:51-56. [PMID: 30978618 DOI: 10.1016/j.clinbiomech.2019.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies have reported that persons with femoroacetabular impingement syndrome (FAIS) have diminished posterior tilt of the pelvis during functional tasks. It is not known how this movement impairment impacts pelvifemoral coordination during weightbearing and non-weightbearing movements. METHODS Fifteen persons with a diagnosis of FAIS and 15 matched controls performed a deep squat (weightbearing) and a maximum height stepping task (non-weightbearing). Peak hip flexion, posterior pelvis tilt excursion, and the ratio of sagittal plane pelvis to femur motion during the period of pelvis posterior tilt were calculated for each task. Two factor ANOVAs were used to evaluate differences between groups and tasks. FINDINGS With regards to peak hip flexion, there were no significant group differences for either task. When averaged across tasks, the FAIS group exhibited significantly less posterior tilt excursion (12.1° (SD 9.1°) vs 20.6° (SD 9.3°)) and smaller pelvifemoral ratios (0.24 (SD 0.14) vs 0.39 (SD 0.16)) compared to the control group. INTERPRETATION Persons with FAIS exhibit altered pelvifemoral coordination regardless of weightbearing status. This finding suggests that decreased hip and/or lumbopelvic mobility may contribute to altered movement patterns at the hip.
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Affiliation(s)
- Jennifer J Bagwell
- Department of Physical Therapy, Creighton University, 2500 California Plaza, Omaha, NE 68178, USA.
| | - Christopher M Powers
- Division of Biokinesiology & Physical Therapy, University of Southern California, 1540 Alcazar Street, CHP-155, Los Angeles, CA 90740, USA.
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Ng KCG, Lamontagne M, Jeffers JRT, Grammatopoulos G, Beaulé PE. Anatomic Predictors of Sagittal Hip and Pelvic Motions in Patients With a Cam Deformity. Am J Sports Med 2018. [PMID: 29517923 DOI: 10.1177/0363546518755150] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As there is a high prevalence of patients with cam deformities and no ongoing hip dysfunction, understanding the biomechanical factors predicting the onset of symptoms and degenerative changes is critical. One such variable is how the spinopelvic parameters may influence hip and pelvic sagittal mobility. Hypothesis/Purpose: Pelvic incidence may predict sagittal hip and pelvic motions during walking and squatting. The purpose was to determine which anatomic characteristics were associated with symptoms and how they influenced functional hip and pelvic ranges of motion (ROMs) during walking and squatting. STUDY DESIGN Controlled laboratory study. METHODS Fifty-seven participants underwent computed tomography and were designated either symptomatic (n = 19, cam deformity with pain), asymptomatic (n = 19, cam deformity with no pain), or control (n = 19, no cam deformity or pain). Multiple femoral (cam deformity, neck angle, torsion), acetabular (version, coverage), and spinopelvic (pelvic tilt, sacral slope, pelvic incidence) parameters were measured from each participant's imaging data, and sagittal hip and pelvic ROMs during walking and squatting were recorded using a motion capture system. RESULTS Symptomatic participants had large cam deformities, smaller femoral neck-shaft angles, and larger pelvic incidence angles compared with the asymptomatic and control participants. Discriminant function analyses confirmed that radial 1:30 alpha angle (λ1 = 0.386), femoral neck-shaft angle (λ2 = 0.262), and pelvic incidence (λ3 = 0.213) ( P < .001) were the best anatomic parameters to classify participants with their groups. Entering these 3 parameters into a hierarchical linear regression, significant regressions were achieved for hip ROM only when pelvic incidence was included for walking ( R2 = 0.20, P = .01) and squatting ( R2 = 0.14, P = .04). A higher pelvic incidence decreased walking hip ROM ( r = -0.402, P = .004). Although symptomatic participants indicated a trend of reduced squatting hip and pelvic ROMs, there were no significant regressions with the anatomic parameters. CONCLUSION A cam deformity alone may not indicate early clinical signs or decreased ROM. Not only was pelvic incidence a significant parameter to classify the participants, but it was also an important parameter to predict functional ROM. Symptomatic patients with a higher pelvic incidence may experience limited sagittal hip mobility. CLINICAL RELEVANCE Patients with symptomatic femoroacetabular impingement showed a higher pelvic incidence and, combined with a cam deformity and varus neck, can perhaps alter the musculature of their iliopsoas, contributing to a reduced sagittal ROM. With an early and accurate clinical diagnosis, athletes could benefit from a muscle training strategy to protect their hips.
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Affiliation(s)
- K C Geoffrey Ng
- Department of Mechanical Engineering, Imperial College London, London, UK.,Human Movement Biomechanics Laboratory, University of Ottawa, Ontario, Canada
| | - Mario Lamontagne
- Human Movement Biomechanics Laboratory, University of Ottawa, Ontario, Canada.,School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada.,Department of Mechanical Engineering, University of Ottawa, Ottawa, Ontario, Canada.,Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - George Grammatopoulos
- Department of Orthopaedics and Trauma, University College London Hospitals NHS Trusts, London, UK
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
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Kinematic Differences During Single-Leg Step-Down Between Individuals With Femoroacetabular Impingement Syndrome and Individuals Without Hip Pain. J Orthop Sports Phys Ther 2018; 48:270-279. [PMID: 29510652 PMCID: PMC6570579 DOI: 10.2519/jospt.2018.7794] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Controlled laboratory study, case-control design. Background Despite recognition that femoroacetabular impingement syndrome (FAIS) is a movement-related disorder, few studies have examined dynamic unilateral tasks in individuals with FAIS. Objectives To determine whether movements of the pelvis and lower extremities in individuals with FAIS differ from those in individuals without hip pain during a single-leg step-down, and to analyze kinematic differences between male and female participants within groups. Methods Individuals with FAIS and individuals without hip pain performed a single-leg step-down while kinematic data were collected. Kinematics were evaluated at 60° of knee flexion. A linear regression analysis assessed the main effects of group, sex, and side, and the interaction of sex by group. Results Twenty individuals with FAIS and 40 individuals without hip pain participated. Individuals with FAIS performed the step-down with greater hip flexion (4.9°; 95% confidence interval [CI]: 0.5°, 9.2°) and anterior pelvic tilt (4.1°; 95% CI: 0.9°, 7.3°) than individuals without hip pain. Across groups, female participants performed the task with more hip flexion (6.1°; 95% CI: 1.7°, 10.4°), hip adduction (4.8°; 95% CI: 2.2°, 7.4°), anterior pelvic tilt (5.8°; 95% CI: 2.6°, 9.0°), pelvic drop (1.4°; 95% CI: 0.3°, 2.5°), and thigh adduction (2.7°; 95% CI: 1.3°, 4.2°) than male participants. Conclusion The results of this study suggest that individuals with FAIS have alterations in pelvic motion during a dynamic unilateral task. The noted altered movement patterns in the FAIS group may contribute to the development of hip pain and may be due to impairments that are modifiable through rehabilitation. J Orthop Sports Phys Ther 2018;48(4):270-279. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7794.
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Trunk, pelvis and hip biomechanics in individuals with femoroacetabular impingement syndrome: Strategies for step ascent. Gait Posture 2018; 61:176-182. [PMID: 29353742 DOI: 10.1016/j.gaitpost.2018.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/04/2018] [Accepted: 01/11/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Femoroacetabular impingment (FAI) syndrome is common among young active adults and a proposed risk factor for the future development of hip osteoarthritis. Pain is dominant and drives clinical decision-making. Evidence for altered hip joint function in this patient population is inconsistent, making the identification of treatment targets challenging. A broader assessment, considering adjacent body segments (i.e. pelvis, trunk) and individual movement strategies, may better inform treatment programs. This exploratory study aimed to compare trunk, pelvis, and hip biomechanics during step ascent between individuals with and without FAI syndrome. METHODS Fifteen participants diagnosed with symptomatic cam-type or combined (cam plus pincer) FAI who were scheduled for arthroscopic surgery, and 11 age-, and sex-comparable pain- and disease-free individuals, underwent three-dimensional motion analysis during a step ascent task. Trunk, pelvis and hip biomechanics were compared between groups. RESULTS Participants with FAI syndrome exhibited altered ipsilateral trunk lean and pelvic rise towards the symptomatic side during single-leg support compared to controls. Alterations were not uniformly adopted across all individuals with FAI syndrome; those who exhibited more pronounced alterations to frontal plane pelvis control tended to report pain during the task. There were minimal between-group differences for hip biomechanics. CONCLUSION Exploratory data suggest biomechanics at the trunk and pelvis during step ascent differ between individuals with and without FAI syndrome. Those with FAI syndrome implement a range of proximal strategies for task completion, some of which may have relevance for rehabilitation. Longitudinal investigations of larger cohorts are required to evaluate hypothesized clinical and structural consequences.
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King MG, Lawrenson PR, Semciw AI, Middleton KJ, Crossley KM. Lower limb biomechanics in femoroacetabular impingement syndrome: a systematic review and meta-analysis. Br J Sports Med 2018; 52:566-580. [DOI: 10.1136/bjsports-2017-097839] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 11/06/2017] [Accepted: 12/18/2017] [Indexed: 12/18/2022]
Abstract
Objective(1) Identify differences in hip and pelvic biomechanics in patients with femoroacetabular impingement syndrome (FAIS) compared with controls during everyday activities (eg, walking, squatting); and (2) evaluate the effects of interventions on hip and pelvic biomechanics during everyday activities.DesignSystematic review.Data sourcesMedline, CINAHL, EMBASE, Scopus and SPORTDiscus until February 2017.MethodsPrimary aim: studies that investigated hip or pelvic kinematics and/or joint torques of everyday activities in patients with FAIS compared with the asymptomatic contralateral limb or a control group. Secondary aim: studies that evaluated effects of conservative or surgical interventions on patients with FAIS using pre-post or controlled clinical trial designs. Biomechanical data must have been collected using three-dimensional motion capture devices. Reporting quality was assessed using the Epidemiological Appraisal Instrument and data were pooled (standardised mean difference (SMD), 95% CI) where populations and primary outcomes were similar.ResultsFourteen studies were included (11 cross-sectional and three pre/post intervention), varying between low and moderate reporting quality. Patients with FAIS walked with a lower: peak hip extension angle (SMD −0.40, 95% CI −0.71 to −0.09), peak internal rotation angle (−0.67, 95% CI −1.19 to −0.16) and external rotation joint torque (−0.71, 95% CI −1.07 to −0.35), and squatted to a lesser depth with no difference in hip flexion range. Pre/post intervention data were limited in number and quality, and to surgical cohorts.ConclusionThis review suggests that patients with FAIS may demonstrate hip biomechanical impairments during walking and squatting, with minimal literature available to comment on other tasks.Clinical relevanceThe information presented in the review provides insight into the biomechanical differences associated with FAIS; however, the between-group differences were small to moderate. This information may aid in the development of management strategies for people with the condition.PROSPEROregistration numberCRD42016038677.
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Anwander H, Beck M, Büchler L. Influence of evolution on cam deformity and its impact on biomechanics of the human hip joint. J Orthop Res 2018; 36:2071-2075. [PMID: 29405367 DOI: 10.1002/jor.23863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 01/24/2018] [Indexed: 02/04/2023]
Abstract
Anatomy and biomechanics of the human hip joint are a consequence of the evolution of permanent bipedal gait. Habitat and behaviour have an impact on hip morphology and significant differences are present even within the same biological family. The forces acting upon the hip joint are mainly a function of gravitation and strength of the muscles. Acetabular and femoral anatomy ensure an inherently stable hip with a wide range of motion. The femoral head in first human ancestors with upright gait was spherical (coxa rotunda). Coxa rotunda is also seen in close human relatives (great apes) and remains the predominant anatomy of present-day humans. High impact sport during adolescence with open physis however can activate an underlying genetic predisposition for reinforcement of the femoral neck, causing an epiphyseal extension and the formation of an osseous asphericity at the antero-superior femoral neck (cam deformity). The morphology of cam deformity is similar to the aspherical hips of quadrupeds (coxa recta), with the difference that in quadrupeds the asphericity is posterior. It has been postulated that this is due to the fact that humans bear weight on the extended leg, while quadrupeds bear weight at 90-100° flexion. The asphericity alters the biomechanical properties of the joint and as it is forced into the acetabulum leading to secondary cartilage damage. It is considered a risk factor for later development of osteoarthritis of the hip. Clinically this presents as reduced range of motion, which can be an indicator for the structural deformity of the hip. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:XX-XX, 2018.
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Affiliation(s)
- Helen Anwander
- Clinic for Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Beck
- Clinic for Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Lorenz Büchler
- Department of Orthopaedic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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