The Influence of Muscular Tightness of Gastrocnemius on the Ankle Joint Reaction Force during Gait

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1 . 弘光學報 52 期. The Influence of Muscular Tightness of Gastrocnemius on the Ankle Joint Reaction Force during Gait Shyi-Kuen Wu 1 Fang-Chuan Kuo 1 Yung-Yuh Tsai 2,4 Yen-Wen Chen 5 Yueh-Ling Hsieh 3 Hong-Ji Luo 2 Jia-Yuan You 6* 1 Assistant Professor, Physical Therapy Department of Hungkuang University 2 Lecturer, Physical Therapy Department of Hungkuang University 3 Associate Professor, Physical Therapy Department of Hungkuang University 4 Department of Physical Medicine and Rehabilitation, Cheng Ching Hospital, Taichung, TAIWAN 5 Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung, TAIWAN 6 Department of Physical Therapy, I-Shou University, Kaoshiung County, TAIWAN Received 19 September 2007 ; accepted 28 November 2007 Abstract Objective. The muscular tightness is a common clinical musculoskeletal problem and is postulated as an intrinsic risk factor for the development of muscle injuries. The purpose of this study was to investigate the influence of the muscular tightness of gastrocnemius on the ankle joint reaction force during gait in order to inform the clinical management of patients with muscular tightness of lower legs. Method. Ten adult subjects (5 males and 5 females) with the muscle tightness of gastrocnemius participated in this study. The motion analysis system and two force plates were applied to capture the gait motions with the standard Helen Hayes marker set. The ground reaction forces and ankle joint reaction forces during the walking trails were compared between the affected (n=10) and unaffected limbs (n=10). Results. Although the kinematic data of gait analysis were quite similar between affected and unaffected limbs, the kinetic findings revealed significantly increased ankle loadings in the affected limbs during gait cycle. The significantly increased peak vertical ground reaction forces [1.85 ± 0.46 times body weight (B.W.) vs 1.30 ± 0.21 B.W., P= 0.003], peak joint compression force in ankle [1.79 ± 0.44 B.W. vs 1.25 ± 0.20 B.W., P= 0.001] were demonstrated in the affected limbs during walking. Conclusion. The results of gait analysis indicated that the muscular tightness of gastrocnemius muscles had an effect on ankle-foot complex. Adequate mobility of ankle-foot joints was necessary for normal attenuation of forces transmitted from the ground to the weight-bearing extremity. The quantitative gait analysis was valuable to clarify the influence of the muscle tightness on the ankle joint reaction forces in the lower extremities. Keywords: muscular tightness, joint reaction force, gait analysis. *Corresponding author 101

2 . 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響. 1.INTRODUCTION The muscular tightness is a common clinical musculoskeletal problem and is postulated as an intrinsic risk factor for the development of muscle injuries (Witvrouw, 2003; Shrier, 2001; Mense, 1993; Gerwin, 1998). Flexibility is an important attribute of a healthy as well as of a physically fit muscle. Muscle tightness could be as a consequence of a certain pathological conditions including chronic repetitive minor muscle strain, poor posture, systemic disease, or neuromusculoskeletal lesion (Witvrouw, 2003; Shrier, 2001; Zito, 2006; Kuukkanen, 2000; Tyler, 1999). The muscular tightness is often accompanied by pain, restricted range of motion, and poor performance. Some researches concerning the muscular tightness have been related to the areas of head, spine, as well as upper extremities, but the lower extremity problems were generally overlooked. Zito et al. (2006) indicated that the cervicogenic headache group had less range of cervical flexion/extension and significantly higher incidences of painful upper cervical joint dysfunction, and neck muscle tightness. Kuukkanen and Malkia (2000) studied the spinal and muscle flexibility as outcome measurements in the rehabilitation of subjects with low back pain. They found the spinal rotation and erector spinae muscle flexibility improved significantly with intensive training. Tyler et al. (1999) documented that increased capsular and muscular tightness of the dominant posterior shoulder in throwing athletes has been associated with the development of altered shoulder rotational motion. It provoked a lack of fluidity due to muscular tightness and resulted in a lack of precision in the throwing action. There is a significant risk of injury when undertaking sports activities because sports activity can overload an athlete s musculoskeletal system in predictable ways, athletic repetition without proper conditioning can propagate muscular imbalance and flexibility deficits. Abnormal muscular tightness of the lower limb has been implicated as a causative factor for injury. Witvrouw et al. (2003) proposed that soccer players with an increased tightness of the hamstring or quadriceps muscles had a statistically higher risk for a subsequent musculoskeletal lesion. Worrell et al. (1991) demonstrated that hamstring-injured athletes had significantly less flexible on their hamstrings (for both sides) compared with a group of matched controls. The muscular tightness of gastrocnemius muscle has been proposed to possibly lead to the nocturnal calf cramp (Prateepavanich, 1999). Although the clinical studies provide significant information regarding the muscular inflexibility, the lack of the quantitative analysis of lower extremities prevents our further understanding of the consequence of the muscular.tightness of the lower legs. Gait is a functional task requiring complex interactions and coordination among the major joints of the body, particularly the lower extremities. The descriptions of typical body movements and of pathological conditions during gait cycle are critical for therapeutic interventions. The previous studies indicated that degrees of dorsiflexion at the ankle joint is needed and occurs during the late stance phase of a normal 102

3 . 弘光學報 52 期. gait cycle (Martin, 1992; Nordin, 2001). However, the muscular tightness is a factor influencing the range of motion (ROM) of joints. Radford et al. (2006) reported that the lower leg muscle tightness and reduced range of ankle joint dorsiflexion were related to a number of lower limb disorders, including Achilles tendinitis and plantar fasciitis. The interventions improving the flexibility of the ankle joint, flexibility of calf muscles, amount of foot pronation, and foot and ankle mechanics (with orthotics) have been implicated in ameliorating symptoms of tendinopathies. (Wilder, 2004). The plantarflexors contract eccentrically during the early stance phase to control the advancement of tibia over the foot, to stabilize the knee, and concentrically during the late stance phase to assist push-off. Therefore, the disturbance at the ankle motion or muscular function may have an effect not only on the ankle-foot complex but also on the remainder joints in the lower extremities. There has been surprisingly no study investigating the influence of muscular tightness of the lower legs on gait performance in normal subjects. Because mobility impairments are likely to result in compensatory movement strategies, recognizing and understanding those strategies may be critical in designing effective interventions for preventing disability. The purpose of this study was to investigate the influence of the muscular tightness of lower legs on the ankle joint reaction force during gait in order to inform the clinical management of patients with muscular tightness of lower legs. 2.METHODS 2.1 Subjects Ten adult subjects (5 males and 5 females) with the muscle tightness of lower legs participate in this study. The passive dorsiflexion at the ankle joint less than 15 degrees were met the inclusion criterion in this study. The subjects were excluded if she/he had (1) history of ankle trauma or surgery, (2) bone pathology, (3) arthritic or other inflammatory, (4) neurological system dysfunction, and (5) ankle or knee symptoms within recent 2 weeks. The locations of gastrocnemius tightness such as taut bands and nodules were over the superiolateral (50%), superiomedial (30%), centrolateral (40%), centromedial (60%), and tendon portions (30%), respectively. The half of our subjects was not aware of the onset of the muscle tightness. The possible causes of the tight gastrocnemius in the remaining five subjects were the excessive running training (3/5), pronated foot (1/5), and previous Achilles tendonitis (2/5). 2.2 Measurement of range of motion at ankle The ROM measurements were performed on the ankle and knee joints. Three trials for each leg are recorded and averaged to yield representative values. Ankle ROM was assessed with a goniometer in knee extended and flexed positions in order to differentiate the tightness of different calf muscles. The subject was in supine with hip and knee extended and was directed to plantarflex. A goniometer was placed on the lateral malleolus, with one arm inline with the 5th metatarsal bone and the other arm in line with the fibular bone. 103

4 . 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響. The procedure was subsequently repeated for the measurement of dorsiflexion. The passive ROMs were assessed during the procedure. Afterwards, the subject flexed the hip and knee to about 90 degrees with leg rest on a stool and the ankle ROM measurements were repeated. 2.3 Laboratory setup and experimental procedure The EVaRT motion analysis system [Motion Analysis Corporation, CA, USA] equipped with 5 cameras were used to capture the subject s motion at 60 Hz sample rate. The gait motion data were synchronized with ground reaction forces measured by two forceplates [AMTI Corporation, USA]. The standard Helen Hayes marker set consisting of 15 reflexive markers were used to identify the lower body segments (Robon, 2000). The markers were on the right and left anterior superior iliac spines [ASIS], sacrum top in line with the spinal plane, right and left mid-thigh, cuff with marker on wand, right and left knee, lateral epicondyle, right and left mid-shank, cuff with marker on wand, right and left lateral malleolus, right and left heel, and right and left foot between 2nd and 3rd metatarsal heads. The computer software Ortho Trak 5.2 [Motion Analysis Corporation, CA, USA] was applied to analyze the joint reaction forces. The subjects were asked to walk at a self-selective pace along the walkway and step on the forceplates. Before the data collection, several practices were allowed to habituate the subject to the testing environment and then ten successful trails were collected for further analysis. 2.4 Statistical analysis The ranges of motion (ROM) and temporal spatial gait parameters were averaged and compared between affected and unaffected limbs. The ground reaction forces and ankle joint reaction forces during the walking trails were compared between affected and unaffected limbs using pair t-tests. Analyses were performed using the Scientific Package for Social Science [version 11; SPSS, IL, USA]. The level of statistical significance in this study was considered as P < RESULTS 3.1 subjects The mean ages of the ten participants were years (female: years; male: years). All subjects had muscular tightness on one limbs and their unaffected limbs served the controls. The body heights and weights were cm and kgw for the female subjects, and cm and kgw for the male ones. 3.2 Range of motion The passive ranges of affected ankle dorsiflexion (8.5 ± 3.3 ) with knee extended were significantly smaller than those of unaffected ankle (15.2 ± 5.2 ; P = 0.006). The ankle range was measured with knee extended and flexed position. The passive ranges of ankles with knee flexed were similar for both affected and unaffected limbs (17.6 ± 3.5 vs ± 3.9 ; P = 0.806). 104

5 . 弘光學報 52 期. 3.2 Temporal spatial and kinematic analysis The subjects walked at a preferred speed approximately at an average of 130 cm/sec. The temporal spatial parameters were listed in Table 1 and did not show significant differences between affected and unaffected legs (P = ). The angular displacements of different joints during walking were found to have the similar patterns in hips, knees, and ankles for both the affected and unaffected limbs. There was a significantly larger peak foot pronation in the affected leg during the stance phase (8.6 ± 3.3 vs. 2.7 ± 2.6 ; P = 0.001)(Figure 1). Figure 1: The angular displacements of ankle and foot joints during gait cycle. The red lines (left panel) represented the affected limb and the blue lines (right panel) were for the unaffected limb. The shadow areas represented the normative patterns of the adult gait. 105

6 . 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響. 3.3 Kinetic analysis There was an increased vertical ground reaction force on two peaks of the affected leg (figure 2). The mean peak compression was significantly greater in the affected limb during the loading response than the normal limb [1.85 ± 0.46 times body weight (B.W.) vs 1.30 ± 0.21 B.W., P= 0.003]. There were no significant differences between affected and unaffected limbs in either lateral or frontal directions [P> 0.05; P> 0.05]. Considering the joint reaction force (JRF) of ankle, though mediolateral components of joint reaction forces were small, the medial joint reaction forces were significantly greater in the affected limb than in the unaffected ones during the push-off period [0.05 ± 0.03 B.W. vs ± 0.07 B.W., P= 0.023].. The mean peak ankle joint compression force was significantly greater in the affected ankle during the loading response than that in the normal limb [1.79 ± 0.44 B.W. vs 1.25 ± 0.20 B.W., P= 0.001] (Figure 3). The statistically greater anterior joint reaction forces were also detected for the affected limbs during the push-off period of gait cycle [0.38 ± 0.14 B.W. vs 0.25 ± 0.11 B.W., P= 0.017]. Figure 2: The three components of the ground reaction forces during gait cycle. The red lines (left panel) represented the affected limb and the blue lines (right panel) were for the unaffected limb. The shadow areas represented the normative patterns of the adult gait. 106

7 . 弘光學報 52 期. Figure 3: The three components of the ankle joint reaction forces during gait cycle. The red lines (left panel) represented the affected limb and the blue lines (right panel) were for the unaffected limb. The shadow areas represented the normative patterns of the adult gait. 4. DISCUSSION The mobility incline could result the change of gait pattern that was less economical or increased muscular effort to produce the same gait pattern because of increased resistance to motion near the ends of ROM (Lamontagne, 2000; Moseley, 2003). The results of gait analysis indicated that the muscular tightness of gastrocnemius muscles had an effect on ankle-foot complex. Although the kinematic data were quite similar except for foot pronation, the kinetic findings such as increased ground reaction forces and joint reaction forces revealed the influence of the muscular tightness on the lower legs. Maximum dorsiflexion at the ankle joint during human gait occurs during stance phase just before heel raise. The passive dorsiflexion ROMs of affected legs were lesser than the range of normal ankle dorsiflexion reported in the literatures (Witvrouw, 2003; Shrier, 2001; Gerwin, 1998). The degrees of dorsiflexion at the ankle joint was needed and occurred during terminal stance phase 107

8 . 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響. of normal gait. Moseley et al. (2003) indicated that the normal ankle dorsiflexion ROM was 18.1 degrees with a standard deviation of 6.9 degrees while the inflexible subjects were less than or equal to 11.2 degrees. Limitation of ankle dorsiflexion may be caused by the muscular tightness of gastrocnemius when the knee is extended, as the muscle spans the two joints. The lesser ranges of ankle dorsiflexion in knee extended positions in the present study indicated that the gastrocnemius muscle was tight and inflexible in the affected limb. In our study, the subjects walked at an average velocity of 130 cm/sec which was consistent with normal non-symptomatic subjects (Lamontagne, 2000; McGibbon, 2001). A preferred walking velocity for individuals was generally close to the most economical speed at 130 cm/sec. It was believed that muscular flexibility declines could result in a modified gait pattern, but the similar angular patterns were found between the affected and unaffected limbs for hip, knee, and ankle joints in flexion-extension angulation. Selby-Silverstein et al. (1997) applied the serial casting for an athlete with shortened gastrocnemius muscles and demonstrated an increase in mean total ankle range of motion without a change in foot pronation. However, the major difference between the affected and unaffected limbs during gait cycle was the extent of foot pronation in the present study. There was a significantly larger foot pronation in the affected leg during the stance phase, though the similar ankle dorsiflexions in stance phase were exhibited in both affected and unaffected ankles. The compensation described by Gross (1995) was an increase in the excessive and prolonged foot pronation, so that dorsiflexion demands during the terminal stance phases of gait were decreased. The scenario that our subjects demonstrated the increased foot pronation in the affected leg could possibly attributed to this compensation for the insufficient dorsiflexion range of the affected ankle. As for the kinetic analysis, the vertical ground reaction forces and joint reaction forces were widely used for studying the kinetic component of gait and were valuable to clinicians in the diagnosis and treatment of gait abnormalities. The subjects revealed the significantly increased vertical ground reaction forces on two peaks and the significantly higher mean ankle joint compression forces of the affected leg during gait cycle. All these information suggested that the greater impact forces could be more demand on dorsiflexor muscle in maintaining an appropriate heel strike on first peak as the result of the muscular tightness of gastrocnemius muscles. On the other hand, Anderson and Pandy (2003) analyzed the individual muscle contributions to the support in walking and the second peak might be explained by the forces exerted by the calf muscles during late stance referred as push-off. Therefore, the reason that our subjects revealed a high second peak could be resulted from walking with the greater efforts of gastrocnemius muscles. Additionally, anterior and medial joint reaction force increased during the push-off period indicated that the maximum joint reaction force across the ankle passed through the anterior medial compartment Our findings indirectly suggested the increases in the foot pronation (collapse of the medial arch) and obligatory increases in gastrocnemius muscle activation during the late 108

9 . 弘光學報 52 期. stance phase (Gross, 1995). Adequate mobility of ankle-foot joints was necessary for normal attenuation of forces transmitted from the ground to the weight-bearing extremity. Decreased mobility was likely to cause abnormal stresses to these joints as well as to the other joints (McGibbon, 2001). The insufficient flexibility could also increase muscular effort because of increased resistance to ankle motion near the extremes of the ROM. Messier et al (1992) reported that the excessive knee flexion angles were the obligatory compensation for tight gastrocnemius muscles in order to have a nearly normal ankle-foot motion. The greater demand of knee extensors might increase knee compressive joint reaction forces and aggravate the knee pain. Normal physical activity requires an intact kinetic chain to create the energy, and transfer the momentum through the joints. Disruption to the kinetic chain could result in increased loading of other joints in the sequence of movements and lead to potential injury (Kibler, 1995). Therefore, one limitation of the present study was the main outcome measurements focused on the ankle-foot areas. The future investigations on the whole joint reaction forces of the lower extremities may be necessary. The insufficient muscular flexibility could contribute to a modified gait pattern that is less economical or increased muscular effort to produce the same gait pattern. The results of gait analysis indicated that muscular tightness of lower legs at the ankle joint had an effect on ankle-foot complex. Although the angular changes throughout the gait cycle at different joints were quite similar, the ground reaction forces and joint reaction forces were significantly greater in the affected limbs. Our study investigated the sequela of muscular tightness on gait performance and demonstrated that the quantitative gait analysis was valuable to clarify the influence of the muscle tightness on joint reaction forces in the lower extremities. The limitation of present study is the biomechanical considerations mainly on the sagittal planes of the ankle-foot areas. Though this analysis method may easily identify the compensation between segments, future researches analyze the whole lower extremity and trunk may reveal more complicated compensatory strategies for the mobility impairment. Acknowledgment This project was supported by the grant number HK-95-B-03 of the HungKuang University. References 1. Witvrouw E, Danneels L, Asselman P, D'Have T, Cambier D. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players. A prospective study. Am J Sports Med 2003;31: Shrier I. Ehrmann-Feldman D. Rossignol M. Abenhaim L. Risk factors for development of lower limb pain in adolescents. J Rheumatol 2001;28: Mense S. Nociception from skeletal muscle in relation to clinical muscle pain. Pain 1993; 54: Gerwin RD. Myofascial pain and fibromyalgia: Diagnosis and treatment. J Back Musculoske Rehabil 1998; 11:

10 . 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響. 5. Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the diagnosis o f c e r v i c o g e n i c h e a d a c h e. M a n T h e r 2006;11: Kuukkanen T, Malkia E. Effects of a three-month therapeutic exercise programme on flexibility in subjects with low back pain. Physiother Res Int 2000;5: Tyler TF, Roy T, Nicholas SJ, Gleim GW. Reliability and validity of a new method of measuring posterior shoulder tightness. J Orthop Sports Phys Ther 1999; 29: Simons DG. Diagnostic criteria of myofascial pain caused by trigger points. J Musculoske Pain 1999; 7: Worrell TW, Perrin DH, Gansneder B, Gieck J. Comparison of isokinetic strength and flexibility measures between hamstring injured and non-injured athletes. J Orthop Sports Phys Ther 1991; 13: Prateepavanich P, Kupniratsaikul V, Charoensak T: The relationship between myofascial trigger points of gastrocnemius muscle and nocturnal calf cramps. J Med Assoc Thai 1999; 82: Martin PE, Morgan DW: Biomechanical considerations for economical walking and running. Med Sci Sports Exerc 1992; 24: Nordin M, Frankel VH: Basic Biomechanics of the Musculoskeletal System. Ed. 3. Williams & Wilkins, Baltimore, 2001, pp Radford JA, Burns J, Buchbinder R, Landorf KB, Cook C. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med 2006; 40: Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med 2004; 23: Lamontagne A, Malouin F, Richards CL. Contribution of passive stiffness to ankle plantarflexor moment during gait after stroke. Arch Phys Med Rehabil 2000;81: Moseley AM, Roger J, Adams R. High and low ankle flexibility and motor task performance. Gait Posture 2003; 18: McGibbon CA, Krebs DE, Puniello MS. Mechanical energy analysis identifies compensatory strategies in disabled elders gait. J of Biomech 2001; 34: Selby-Silverstein L, Farrett WD Jr, Maurer BT, Hillstrom HJ. Gait analysis and bivalved serial casting of an athlete with shortened gastrocnemius muscles: a single case design. J Orthop Sports Phys Ther 1997; 25: Gross MT. Lower quarter screening for skeletal malalignment- suggestions for orthotics and shoewear. J Orthop Sports Phys Ther. 1995;21: Anderson FC, Pandy MG. Individual muscle contributions to support in normal walking. Gait Posture 2003; 17: Messier SP, Loeser RF, Hoover JL, Semble EL, Wise CM. Osteoarthritis of the knee: Effect on gait, strength, and flexibility. Arch Phys Med Rehabil 1992; 73: Kibler WB. Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995; 14:

11 . 弘光學報 52 期. 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響 吳錫昆 1 郭芳娟 1 蔡永裕 2,4 陳彥文 5 謝悅齡 3 羅鴻基 2 游家源 6 * 1 弘光科技大學物理治療系助理教授 2 弘光科技大學物理治療系講師 3 弘光科技大學物理治療系副教授 4 澄清綜合醫院復健治療部 5 臺中榮民總醫院復健科 6 義守大學物理治療系 收到日期 : 修訂日期 : 接受日期 : 摘要 目的 : 肌肉緊縮是一種臨床常見之骨骼肌肉問題, 且被認為易導致肌肉受傷的內在危險因素之一 本研究的目是探討小腿腓腸肌緊縮於步態期間對踝關節作用力之影響, 以提供臨床人員在處理小腿肌肉緊縮病患的建議 方法 : 十位具有小腿肌肉緊縮的成年人 (5 位男性和 5 位女性 ) 參與本研究, 本研究使用標準 Helen Hayes 的反光球標識器, 藉由動作分析系統和兩塊測力板來擷取受測者的步態運動資料 步態期間小腿肌肉緊縮之患側 (n=10) 及正常健側 (n=10) 採取統計分析比較其地面反作用力和踝關節作用力 結果 : 雖然步態運動學 (kinematics) 顯示患側及正常健側幾乎相似的活動範圍資料, 動力學 (kinetics) 研究顯示肌肉緊縮的下肢相較於正常下肢有明顯增加之踝關節負荷 步態時有明顯增加之尖峰垂直地面反作用力 [ 倍體重 vs 倍體重, P= 0.003], 踝關節尖峰關節壓迫作用力 [ 倍體重 vs 倍體重, P= 0.001], 發生於腓腸肌緊縮的下肢 結論 : 步態分析的結果顯示下肢腓腸肌肉緊縮會影響踝關節及足部範圍 足夠的踝關節及足部活動度, 對於減少地面傳導到負荷重量下肢之作用力是必要的 定量之步態分析是有價值的, 以定義出小腿肌肉緊縮於步態期間對踝關節作用力之影響 關鍵詞 : 肌肉緊縮 關節作用力 步態分析 * 通訊作者 111

12 112. 小腿腓腸肌緊縮於步態期間對踝關節作用力之影響.

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