Downhill walking: A stressful task for the anterior cruciate ligament?

Abstract

Accelerated rehabilitation after anterior cruciate ligament (ACL) reconstruction has become increasingly popular. Methods employed include immediate extension of the knee and immediate full weight bearing despite the risks presented by a graft pull-out fixation strength of 200–500 N. The purpose of this study was to calculate the tibiofemoral shear forces and the dynamic stabilising factors at the knee joint for the reasonably demanding task of downhill walking, in order to determine whether or not this task presented a postoperative risk to the patient. Kinematic and kinetic data were collected on six male and six female healthy subjects during downhill walking on a ramp with a 19% gradient. Planer net joint moments and mechanical power at the knee joint were calculated for the sagittal view using a force platform and videographic records together with standard inverse dynamics procedures. A two-dimensional knee joint model was then utilised to calculate the tibiofemoral shear and compressive forces, based on the predictions of joint reaction force and net moment at the knee. Linear envelopes of the electromyographic (EMG) activity recorded from the rectus femoris, gastrocnemius and biceps femoris muscles were also obtained. The maximum tibiofemoral shear force occurred at 20% of stance phase and was, on average, 1.2 times body weight (BW) for male subjects and 1.7 times BW for female subjects. The tibiofemoral compressive force was 7 times BW for males and 8.5 times BW for females during downhill walking. The hamstring muscle showed almost continuous activity throughout the whole of the stance phase. The gastrocnemius muscle had its main activity at heelstrike, with a second brust during the late stance phase. Knee joint shear force predictions of approximately 1000 N for a 70-kg subject greatly exceed the strength of a typical ACL graft fixation and muscular stabilisation of the knee is therefore vital to joint integrity. The hamstring muscle shows almost continuous activity during the stance phase and thereby affords some stability, but the gastrocnemius is also seen to be an important stabiliser of the knee joint in the presence of increased shear forces during early stance. Associated stability to the knee joint is indicated by compressive loadings of 7–8 times BW across the tibiofemoral joint. Whereas under normal circumstances there is sufficient dynamic joint stabilisation during downhill walking, the muscular impairment often arising postoperatively from disturbed proprioception could endanger an ACL graft. Therefore downhill walking should be avoided during the postoperative phase in order to protect the reconstruction.