Effects of experimentally-induced anterior knee pain on knee joint position sense in healthy individuals.

PURPOSE: The ability to sense the position of limb segments is a highly specialised proprioceptive function important for control of movement. Abnormal knee proprioception has been found in association with several musculoskeletal pathologies but whether nociceptive stimulation can produce these proprioceptive changes is unclear. This study evaluated the effect of experimentally induced knee pain on knee joint position sense (JPS) in healthy individuals. STUDY DESIGN: Repeated measures, within-subject design. METHODS: Knee JPS was tested in 16 individuals with no history of knee pathology under three experimental conditions: baseline control, a distraction task and knee pain induced by injection of hypertonic saline into the infrapatellar fat pad. Knee JPS was measured using active ipsilateral limb matching responses at 20 degrees and 60 degrees flexion whilst non-weightbearing (NWB) and 20 degrees flexion single leg stance. During the tasks, the subjective perception of distraction and severity of pain were measured using 11-point numerical rating scales. RESULTS: Knee JPS was not altered by acute knee pain in any of the positions tested. The distraction task resulted in poorer concentration, greater JPS absolute errors at 20 degrees NWB, and greater variability in errors during the WB tests. There were no significant correlations between levels of pain and changes in JPS errors. Changes in JPS with pain and distraction were inversely related to baseline knee JPS variable error in all test positions (r=-0.56 to -0.91) but less related to baseline absolute error. CONCLUSION: Knee JPS is reduced by an attention-demanding task but not by experimentally induced pain.     

Abnormal knee joint position sense in individuals with patellofemoral pain syndrome.

The purpose of this cross-sectional study was to compare knee joint position sense (JPS) in 20 individuals with and 20 without patellofemoral pain syndrome (PFPS). Five active tests with ipsilateral limb matching responses were performed at 20 degrees and 60 degrees flexion under non-weightbearing conditions, and at 40 degrees flexion under uni- and bi-lateral weightbearing conditions. The response errors were calculated as the difference between each target and response position (accuracy) and the standard deviation of these differences (reliability). JPS was: (i) significantly less accurate and less consistent in the knees with PFPS during both the non-weightbearing and weightbearing tests when compared to the control subject knees; (ii) less accurate when the symptomatic and asymptomatic knees of the 12 uni-lateral PFPS subjects were compared and (iii) less accurate in the asymptomatic knees of the uni-lateral PFPS subjects and knees of the control subjects. The maximum intensity of pain experienced during each knee JPS test was not correlated to any of the JPS test results. The results confirm abnormal knee joint proprioception in individuals with PFPS. Although it cannot be determined whether the abnormality precedes or follows the development of PFPS, the results support including proprioceptive reeducation in management of PFPS.     

The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain

STUDY DESIGN: A two-group experimental design with repeated measures on one factor was used. OBJECTIVES: To investigate the role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. SUMMARY OF BACKGROUND DATA: Proprioceptive deficits have been identified in patients with low back pain. The underlying mechanisms, however, are not well documented. METHODS: Lumbosacral position sense was determined before, during, and after lumbar paraspinal muscle vibration in 23 young patients with low back pain and in 21 control subjects. Position sense was estimated by calculating the mean absolute error, constant error, and variable error between six criterion and reproduction sacral tilt angles. RESULTS: Repositioning accuracy was significantly lower in the patient group than in healthy individuals (absolute error difference between groups = 2.7 degrees, P < 0.0001). Multifidus muscle vibration induced a significant muscle-lengthening illusion that resulted in an undershooting of the target position in healthy individuals (constant error = -3.1 degrees, P < 0.0001). Conversely, the position sense scores of the patient group did not display an increase in negative directional error but a significant improvement in position sense during muscle vibration (P < 0.05). No significant differences in absolute error were found between the first and last trial in the healthy individuals (P >/= 0.05) and in the patient group (P > 0.05). CONCLUSIONS: Patients with low back pain have a less refined position sense than healthy individuals, possibly because of an altered paraspinal muscle spindle afference and central processing of this sensory input. Furthermore, muscle vibration can be an interesting expedient for improving proprioception and enhancing local muscle control.     

Proprioception, kinesthesia, and balance after total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses

BACKGROUND: The effect of total knee arthroplasty on proprioception, kinesthesia, and postural control remains controversial. It is argued that retaining the posterior cruciate ligament may help to preserve these sensorimotor functions and improve the longevity of the prosthesis and the functional outcome. We performed a prospective, randomized study to assess proprioception, kinesthesia, and balance following total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses. METHODS: Twenty patients scheduled to undergo total knee arthroplasty were randomly assigned to receive either a cruciate-retaining or a posterior stabilized prosthesis. Joint-position sense, the threshold to detect joint motion, and the subject's ability to balance on an unstable platform were assessed prior to and at least six months after the operation. Paired two-tailed t tests (with a level of significance of p < 0.05) were used to assess the effect of the arthroplasty on the preoperative measures for all subjects. Analysis of covariance was performed to identify the effects of prosthetic design. RESULTS: Following total knee arthroplasty, patients detected motion significantly faster and reproduced joint position with less error. The balance index also improved significantly from the preoperative to the postoperative evaluation. The group treated with the posterior stabilized prosthesis more accurately reproduced joint position when the knee was extended from a flexed position. CONCLUSIONS: Total knee arthroplasty results in mild improvements in proprioception, kinesthesia, and balance. These changes may result from the retensioned capsuloligamentous structures and reduced pain and inflammation. Retention of the posterior cruciate ligament does not appear to significantly improve proprioception and balance compared with those functions in patients with a posterior stabilized total knee design.     

Joint position sense in total knee arthroplasty

Seventeen postoperative total knee arthroplasty (TKA) patients were evaluated using two tests of knee joint position sense. Young controls and age-matched controls underwent identical tests. The TKA patients also underwent gait analysis, including foot switch stride analysis, and clinical evaluation using a standard scoring system. Results showed statistically significant decreases in joint position sense from young controls to old controls, and further significant decreases with joint disease; however, no further worsening was noted as a result of TKA. The abnormal gait parameters seen in TKA patients correlated as well with position sense as with clinical score. Strongest correlations were seen when a combined clinical and proprioceptive score was compared with gait parameters. In spite of alleviation of pain and correction of deformity, normal gait and function are not typically achieved after total knee replacement. Irreversible loss of joint proprioceptive function due to the disease process may be a major factor in the discrepancy between clinical and functional outcomes of total joint arthroplasty. Furthermore, loss of proprioception and the resulting abnormal gait patterns may place increased stress on components and contribute to loosening. In addition, an association between degenerative joint disease and decline in proprioception is suggested.     

Hip and knee joint rotations differ between patients with medial and lateral knee osteoarthritis: gait analysis of 30 patients and 15 controls.

The motions and moments in the hip and knee in female patients on the waiting list for knee prosthesis surgery with medial (n = 15) or lateral (n = 15) osteoarthritis (OA) were compared with a control group (n = 15). We hypothesized that not only the kinematics and kinetics of the knee but also of the hip would differ between patients the medial and lateral groups. At midstance, patients with lateral OA showed slightly (2 degrees) more maximal (peak) adduction (p = 0.015) of the hip joint and patients with medial OA had 7 degrees more abduction (p < 0.001) than did controls. In patients with lateral OA, the femur was positioned in about 7 degrees more maximum external rotation (p = 0.001), but femur position did not differ between medial OA and controls (p > or = 0.8). There was a tendency to higher internal hip rotation moment in lateral OA compared to controls (p = 0.021). The maximum values of the internal knee abduction moments were 52% higher in medial OA (p = 0.005) and 63% lower in lateral OA (p < 0.001) compared to controls. Cases with medial OA had 9 degrees more, whereas those with lateral OA had 6 degrees less external tibial rotation than controls (medial vs. lateral OA, p = 0.001). We found an association between presence of lateral OA of the knee and the biomechanics of the hip joint. It remains to be evaluated if the changed biomechanics of the hip joint is a reason for development of lateral OA or an observation that is a result of this disease.     

Sensitivity of gait parameters to the effects of anti-inflammatory and opioid treatments in knee osteoarthritis patients

The study aim was to address the need for objective markers of pain-modifying interventions by testing the hypothesis that selective gait measures of knee joint loading can distinguish differences between non-steroidal anti-inflammatory (NSAID), analgesic treatment (opioid-receptor agonist), and placebo in patients medial knee osteoarthritis (OA). A randomized, single-blind washout, double-blind treatment, double-dummy cross-over trial using three treatment arms placebo, opioid (Oxycodone), and NSAID (Celecoxib) in medial compartment knee OA patients. Six patients with Kellgren-Lawrence radiographic severity grades of 2 or 3 completed six testing sessions (gait and pain assessment) at 2-week intervals. A significant increase was found in the knee total reaction moment and vertical ground reaction force (GRF) for Celecoxib compared to placebo (p=0.005, p=0.003), but not for Oxycodone compared to placebo (p=0.20, p=0.27) treatments. Walking speed was significantly higher for the Celecoxib and Oxycodone compared to placebo treatment (p=0.041 and p=0.031, respectively). Self-reported function (WOMAC scores) was not different among treatments (p>0.05). The changes in total reaction moments and GRFs for only the NSAID suggest that greater increases in joint loading occurs when joint inflammation is treated in addition to pain. The total knee reaction moment, representing the magnitude of the extrinsic moment, appears to be a sensitive marker, more so than self-reported metrics, for evaluating knee OA treatment effects.     

Effect of fatigue on knee proprioception: implications for dynamic stabilization

The high incidence of injuries that occur later during a session of sports or recreational activities suggests that fatigue may contribute to altered neuromuscular control of the lower limb and an individual's subsequent altered ability to dynamically stabilize the knee joint. One possible mechanism is a fatigue-mediated alteration in proprioception. This paper reviews experimental evidence of fatigue-induced changes in knee joint position sense and movement sense, or kinesthesia. We will discuss the possible physiological mechanisms behind these changes, including the role of joint and muscle receptors in proprioception and neuromuscular control of the knee, and the role of fatigue in changes in afferent output from muscle and joint receptors. We will then explore the implications that alteration in proprioception may have for dynamic stabilization of the knee joint.     

Clinical predictors of elective total joint replacement in persons with end-stage knee osteoarthritis

Background  

Arthritis is a leading cause of disability in the United States. Total knee arthroplasty (TKA) has become the gold standard to manage the pain and disability associated with knee osteoarthritis (OA). Although more than 400 000 primary TKA surgeries are performed each year in the United States, not all individuals with knee OA elect to undergo the procedure. No clear consensus exists on criteria to determine who should undergo TKA. The purpose of this study was to determine which clinical factors will predict the decision to undergo TKA in individuals with end-stage knee OA. Knowledge of these factors will aid in clinical decision making for the timing of TKA.     

Efficacy of a target-matching foot-stepping exercise on proprioception and function in patients with knee osteoarthritis

STUDY DESIGN: A randomized clinical trial design. OBJECTIVE: To investigate the efficacy of high, repetitive, target-matching foot-stepping exercise (TMFSE) performed in a sitting position on proprioception, functional score, and walking velocity for patients with knee osteoarthritis (OA). BACKGROUND: Researchers have suggested that exercises to address knee OA should include proprioceptive training. However, most patients cannot tolerate conventional proprioceptive training performed in a standing position. METHODS AND MEASURES: Forty-nine subjects (mean age +/- SD, 63.3 +/- 8.1) with knee OA were randomly assigned to the exercise or no intervention groups. The exercise group practiced TMFSE in sitting, 3 sessions weekly for 6 weeks. All subjects underwent assessments of knee reposition error, functional incapacity score, and walking velocity prior to and after intervention. RESULTS: The TMFSE significantly improved reposition error from a mean +/- SD of 3.0 degrees +/- 1.6 degrees to 1.5 degrees +/- 0.6 degree, walking velocity on ground level from 44.1 +/- 2.9 to 38.6 +/- 2.5 sec for 60 meters, time to complete a stairs task from 34.2 +/- 2.1 to 26.5 +/- 2.3 seconds, time to complete a figure-of-eight from 51.3 +/- 6.7 to 29.1 +/- 3.6 seconds, and score on a functional incapacity scale from 12.0 +/- 3.1 to 4.9 +/- 1.7, in subjects with knee OA after 6-week intervention (P <.0125). In contrast, the control group showed no change in any of the measured tests. CONCLUSION: TMFSE in sitting appears to be an option for exercise in patients with mild to moderate knee OA. This may be an especially attractive option for patients who may have pain with weight-bearing exercises. A longitudinal study with a larger sample size is needed to confirm the potential use of TMFSE for patients with knee OA.     

Knee varus-valgus motion during gait--a measure of joint stability in patients with osteoarthritis?

OBJECTIVE: To determine the validity of varus-valgus motion as a measure of knee joint stability by establishing the relationship of varus-valgus motion with muscle strength, joint proprioception, joint laxity and skeletal alignment in patients with knee osteoarthritis (OA). METHODS: Sixty-three patients with OA of the knee were tested. Varus-valgus motion was determined with a video-based optoelectronic gait analysis system. Muscle strength was measured using a computer-driven isokinetic dynamometer. Proprioceptive acuity was assessed by establishing the joint motion detection threshold in the anterior-posterior direction. Laxity was assessed using a device which measures the passive angular deviation of the knee in the frontal plane. Alignment was assessed using a goniometer. Regression analyses were performed to assess the relationship between varus-valgus motion, muscle strength, joint proprioception, joint laxity and skeletal alignment. RESULT: Varus-valgus motion was not related to muscle strength, joint proprioception, joint laxity and skeletal alignment. CONCLUSIONS: Knee joint stability cannot be measured as varus-valgus motion. Rather, a number of independent factors seem to contribute to the process of stabilization of the knee joint.     

前交叉韧带重建术后膝关节位置觉和运动觉的早期观察研究

目的观察关节镜下自体胭绳肌腱单双束重建前交叉韧带患者术后早期膝关节位置觉和运动觉的恢复情况,并比较有无差异。方法50例单侧前交叉韧带损伤后重建患者非随机分为两组,单束重建组26例,双束重建组24例,移植物均为自体胭绳肌腱;正常对照组12例。术后对患者进行KT2000关节测量,膝关节被动位置重现和运动感知阈值测量,同时对其IKDC2000膝关节主观功能评分和Lysholm膝关节评分进行观察;对照组进行双侧膝关节被动位置重现和运动感知闽值测量。结果比较两组病例术后膝关节的前向稳定性和功能评分以及位置觉和运动觉结果,差异均无统计学意义（P〉0．05）;两病例组与正常对照组相比较,位置觉和运动觉结果差异均有统计学意义（P〈0．05）。结论前交叉韧带重建术后早期患者膝关节的位置觉和运动觉并未恢复到正常水平;前交叉韧带单束重建术和双束重建术患者术后早期膝关节位置觉和运动觉恢复水平并无差异。     

Complete anterior cruciate ligament tear and the risk for cartilage loss and progression of symptoms in men and women with knee osteoarthritis

OBJECTIVE: To determine whether a complete anterior cruciate ligament (ACL) tear, a frequent incidental finding on magnetic resonance imagings (MRIs) of individuals with established knee osteoarthritis (OA), increases the risk for further knee OA progression. METHODS: We examined 265 participants (43% women) with symptomatic knee OA in a 30-month, prospective, natural history study of knee OA. The more symptomatic knee was imaged using MRI at baseline, 15 and 30 months. Cartilage was scored at the medial and lateral tibiofemoral joint and at the patellofemoral joint using the Whole-Organ MRI Score (WORMS) semi-quantitative method. Complete ACL tear was determined on baseline MRI. At each visit, knee pain was assessed using a knee-specific visual analog scale and physical function was assessed using the Western Ontario and McMaster Universities (WOMAC) physical function subscale. RESULTS: There were 49 participants (19%) with complete ACL tear at baseline. Adjusting for age, body mass index, gender and baseline cartilage scores, complete ACL tear increased the risk for cartilage loss at the medial tibiofemoral compartment [odds ratio (OR): 1.8, 95% confidence interval (CI): 1.1, 3.2]. However, following adjustment for the presence of medial meniscal tears, no increased risk for cartilage loss was further seen (OR: 1.1, 95% CI: 0.6, 1.8). Knee pain and physical function were similar over follow-up between those with and without a complete ACL tear. CONCLUSIONS: Individuals with knee OA and incidental complete ACL tear have an increased risk for cartilage loss that appears to be mediated by concurrent meniscal pathology. The presence of a complete ACL tear did not influence the level of knee pain or physical function over short-term follow-up.     

Association of bilateral flat feet with knee pain and disability in patients with knee osteoarthritis: A cross‐sectional study

This cross‐sectional study examined the relationship of flat feet with knee pain, disability, and physical performance in patients with knee osteoarthritis (OA). Orthopedic clinic participants (n = 95; age 61–91 years; 68.4% women) with Kellgren‐Lawrence (K/L) grade ≥1 in the medial compartment underwent evaluation of navicular height and foot length for flat feet. Knee pain intensity, disability, and physical performance were evaluated using the Japanese Knee Osteoarthritis Measure, 10‐m walk, timed up and go, and five‐repetition chair stand tests. Of the 95 enrolled patients, 24 (25.3%) had bilateral flat feet, and significantly higher knee pain compared to patients with no flat feet (11.3 ± 8.23 points vs. 6.58 ± 6.37 points; p = 0.043). A ordinal logistic regression analysis showed that bilateral flat feet were significantly associated with increased knee pain (proportional odds ratio: 5.48, 95% confidence interval: 1.96, 15.3; p = 0.001) compared with no flat feet, adjusted for age, sex, body mass index, and tibiofemoral joint K/L grade, which is consistent across various different cutoffs of the definition of flat feet. Physical performance was similar between patients with and without bilateral flat feet. The presence of unilateral flat feet was not significantly associated with any outcome measures. These findings indicate that bilateral, but not unilateral, flat feet are associated with worse knee pain. A prospective study investigating a causal relationship between bilateral flat feet posture and knee pain as well as disability would be of particular interest to verify the potential adverse effect of altered foot posture. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2490–2498, 2017.

     

Impulse-forces during walking are not increased in patients with knee osteoarthritis

Background?Impulsive forces in the knee joint have been suspected to be a co-factor in the development and progression of knee osteoarthritis. We thus evaluated the impulsive sagittal ground reaction forces (iGRF), shock waves and lower extremity joint kinematics at heel strike during walking in knee osteoarthritis (OA) patients and compared them to those in healthy subjects.

Subjects and methods?We studied 9 OA patients and 10 healthy subjects using three-dimensional gait analyses concentrated on the heel strike. Impulse GRF (iGRF) was measured together with peak accelerations (PA) at the tibial tuberosity and sacrum. Sagittal lower extremity joint angles at heel strike were extracted from the gait analyses. As OA is painful and pain might alter movement strategies, the patient group was also evaluated following pain relief by intraarticular lidocaine injections.

Results?The two groups showed similar iGRF, similar tibial and sacral PA, and similar joint angles at heel strike. Following pain relief, the OA patients struck the ground with more extended hip and knee joints and lower tibial PA compared to the painful condition. Although such changes occurred after pain relief, all parameters were within their normal ranges.

Interpretation?OA patients and healthy subjects show similar impulse-forces and joint kinematics at heel strike. Following pain relief in the patient group, changes in tibial PA and in hip and knee joint angles were observed but these were still within the normal range. Our findings make us question the hypothesis that impulse-forces generated at heel strike during walking contribute to progression of OA.     

Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons

A total of 108 patients with unilateral instability of the knee, associated with rupture of the anterior cruciate ligament, was prospectively randomised for arthroscopic single- or double-bundle reconstruction of the ligament using hamstring tendons. The same post-operative rehabilitation protocol was used for all. The patients were followed up for a mean of 32 months (24 to 36). We measured the anterior laxity and joint position sense at different angles of flexion of the knee to determine whether both bundles in the double-bundle reconstruction contributed to the stability of the joint and proprioception. No significant difference was found between the two groups with regard to anterior laxity measured by the KT-2000 arthrometer with the knee at 20 degrees or 70 degrees flexion nor with regard to proprioception. A notchplasty was required less often in the double- compared with the single-bundle reconstruction. We did not find any advantage in a double-bundle as opposed to a single-bundle reconstruction in terms of stability or proprioception.     

Thoracolumbar proprioception in individuals with and without low back pain: intratester reliability,clinical applicability,and validity

STUDY DESIGN: Repeated measures design of active spinal position sense in individuals with and without low back pain (LBP). OBJECTIVES: Reproducibility and validity evaluation of thoracolumbar proprioception measurement. BACKGROUND: Proprioception studies in peripheral joints and the spine suggest that there may be proprioception deficits due to injury, pain, or degeneration. Kinesthetic retraining may be useful in rehabilitation of patients with LBP, but appropriate measures are required to objectively quantify spinal proprioception. METHODS AND MEASURES: Active-target reproduction in the sagittal, horizontal, and coronal planes was assessed (3 separate occasions for 18 asymptomatic volunteers and 2 occasions for 62 patients with LBP). Repositioning accuracy was expressed as absolute errors (AE) and variable errors (VE). Reliability was analyzed with intraclass correlation coefficient (ICC) and precision with standard error of measurement (SEM) and calculation of the smallest detectable difference (SDD) index. Repeated measures ANOVA and correlations were used for within-group comparisons and discriminant analysis for between-group comparisons. RESULTS: Reproducibility was better for the asymptomatic group, with AE for flexion and rotation being the most reliable (ICC = 0.76-0.80, SEM = 0.91 degrees-1.34 degrees). SDDs were high for all tests, suggesting limited clinical applicability. Reproducibility for the same tests was poor-moderate (ICC = 0.31-0.64, SEM = 0.45 degrees-3.90 degrees) for the patient group. AE for right-side rotation could discriminate between subject groups with 83.3% specificity but only 54.8% sensitivity. CONCLUSIONS: Proprioception testing, with the methods employed, did not demonstrate good measurement properties in a sample of patients with recurrent LBP. Neither could it sufficiently discriminate between individuals with and without LBP. Possible reasons for these findings are discussed.     

A systematic review of the effects of platelet rich plasma on outcomes for patients with knee osteoarthritis and following total knee arthroplasty

Introduction

Platelet rich plasma (PRP) has been suggested to be effective in the management of knee osteoarthritis. Review of current literature reveals conflicting evidence regarding the benefits of PRP in treating knee OA. Preclinical evidence supports the use of PRP injections to promote a favorable environment for joint tissue healing, targeting not only cartilage but also synovial and meniscal tissues which has a positive effect on delaying the progression of OA. Growth factors found in platelet granules are postulated to influence outcomes in knee OA and after total knee arthroplasty (TKA).