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Postural orientation in subjects with anterior cruciate ligament injury: development and first evaluation of a new observational test battery

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Anterior cruciate ligament (ACL) injury is associated with mechanical instability and defective neuromuscular function, and can lead to further injury, increased joint loading and osteoarthritis. Patients with ACL injury demonstrate altered postural orientation, manifested as observable “substitution patterns” (SPs) but no one has applied a clinically useful method to systematically study postural orientation in these patients. Here, we investigated the presence of such patterns in 24 adults with ACL injury and in 49 controls, in parallel with the development and a first evaluation of a new test battery, test for SPs. The rationale behind the test for SPs was to characterize postural orientation as the ability to maintain appropriate relationships between body segments and environment during weight-bearing movements. In this first study, patients displayed SPs more frequently and/or more clearly on their injured, but also their uninjured side than did controls. Inter-rater and intra-rater reproducibility was good at a group level. Future studies of validity, responsiveness and including other subgroups of patients with ACL injury will have to prove if the test for SPs can be used in the diagnostics of defective neuromuscular function following knee injury, when planning and carrying out training and rehabilitation and when deciding appropriate time to return to activity and sports after ACL injury.

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Acknowledgments

The authors are very grateful to late Dr. RTP Rose Zätterström, who designed the first version of the TSP. We are also very grateful to Dr. Jonas Björk for expert advice on statistics, to Associate Professor Anders Lindstrand and to Professor Jan Lexell for valuable contributions to design and acquisition of data in the early stages of the study. This work was supported by the Swedish National Centre for Research in Sports, Region Skåne, Ann-Mari and Ragnar Hemborg’s Research Foundation and by the Faculty of Medicine, Lund University, Sweden. Anna Trulsson and Martin Garwicz were funded by the Swedish Research Council, Projects no. 14015 (PI Martin Garwicz) and 60012701 (a Linné grant to the Neuronano Research Center), respectively.

Conflict of interest statement

The authors report no conflict of interest for this manuscript.

Author information

Authors and Affiliations

  1. Department of Health Sciences, Division of Physical Therapy, Lund University, Lund, Sweden

    Anna Trulsson & Eva Ageberg

  2. Unit for Specialized Pain Rehabilitation, Department of Rehabilitation, Lund University Hospital, 221 85, Lund, Sweden

    Anna Trulsson

  3. Neuronano Research Center, Department of Experimental Medical Science, Lund University, Lund, Sweden

    Martin Garwicz

  4. Department of Orthopedics, Clinical Sciences, Lund University, Lund, Sweden

    Eva Ageberg

Authors
  1. Anna Trulsson
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  2. Martin Garwicz
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  3. Eva Ageberg
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Corresponding author

Correspondence to Anna Trulsson.

Appendix

Appendix

Test for substitution patterns

A—Pelvic lift with support from one foot

Substitution patterns:

  • A1. Knee medial to the foot (knee not in line with hip and foot) on supported side

  • A2. Lateral displacement of hip–pelvis-region on the supported side

  • A3. Difficulty in lifting the seat 5 times/side

B—Body-weight-altering test

Substitution patterns:

  • B1. Increased pronation of supported foot

  • B2. Knee medial to the foot (knee not in line with hip and foot) on supported side

  • B3. Lateral displacement of hip–pelvis region on the supported side

  • B4. Displacement of trunk (for instance bending trunk forward or displacing trunk laterally) on supported side

  • B5. Displacement of arms (look at elbows) such as moving arms laterally or forward on supported side

C—Tip-toe standing knee flexion

Substitution patterns:

  • C1. Knee medial to the foot (knee not in line with hip and foot) on supported side

  • C2. Lateral displacement of hip–pelvis region on the supported side

  • C3. Displacement of trunk (for instance bending trunk forward or displacing laterally) on supported side

D—Rising up from half-kneeling

Substitution patterns:

  • D1. Body weight displaced to the front leg (despite instructions not to do so)

  • D2. Displacement of trunk (for instance bending trunk forward or trying to raise with extra help from arms) on supported side

E—Knee-flexion–extension standing on one leg

Substitution patterns:

  • E1. Increased pronation of supported foot

  • E2. Knee medial to the foot

  • E3. Lateral displacement of hip–pelvis region on supported side

  • E4. Displacement of trunk (for instance bending trunk exaggeratedly forward or displacing trunk laterally) on supported side

F—One-leg-standing bouncing on trampoline

Substitution patterns:

  • F1. Increased pronation of supported foot

  • F2. Knee medial to the foot (knee not in line with hip and foot) on supported side

  • F3. Lateral displacement of hip–pelvis region on supported side

  • F4. Displacement of trunk (bending trunk forward or displacing trunk laterally) on supported side

  • F5. Difficulty doing the exercise with flexibility in flexion–extension in the knee joint when bouncing (“stiff knee”)

  • F6. Head displaced; not in line with trunk

G—Forward lunge from stairs

Substitution patterns:

  • G1. Shorter stride

  • G2. Knee medial to the foot (knee not in line with hip and foot) on supported side

  • G3. Displacement of trunk (for instance bending trunk forward or displacing laterally) on supported side

  • G4. Subject tries to help out with support from hands or takes a more careful stride (sound muffled when foot meets floor)

  • G5. Avoids weight-bearing on hind leg during return

H—Walking backwards on treadmill

Substitution patterns:

  • H1. Limp

  • H2. Increased pronation of supported foot

  • H3. Circular movement with foot in swing phase

  • H4. Knee medial to the foot (knee not in line with hip and foot) on supported side

  • H5. Displacement of trunk (for instance bending trunk forward or displaced laterally) on supported side

  • H6. Displacement of arms (look at elbows) such as: moving arms laterally or forward on supported side

  • H7. “Heel-drop” when either side was weight-bearing (meaning; the whole foot met the treadmill on the supported leg instead of a step starting with support from the big-toe ending with heel-support)

J—Mini-squat

Substitution pattern:

  • J1. Displacement of bodyweight to either side

Starting positions (S) and performance (P)

Test A. Supine position: pelvic lift with support of one foot

S: Subject lying supine on a bench with pillow under head, one knee bent about 90° and foot placed on bench in line with hip and knee. Other leg pulled towards abdomen through flexion in hip and knee. Arms rested aside body. P: Instructions: “Push chin down towards chest, press the hollow of your back into the bench, lift seat up and down slowly 5 times.” Subject repeats the exercise in the same way with the other leg. Examiner standing at the head of and beside the bench.

Test B. Standing position: body-weight-altering test

S: Subject standing barefoot with feet a good hip-width apart. Hands placed on head. P: Instructions: “Alternate body weight from right to left leg at the same time as you bend the supporting leg slightly at ankle, knee and hip joints. Do this slowly alternating the right and the left leg; five times on each side. Look straight ahead.” Examiner standing in front of subject.

Test C. Tiptoe-standing position: tiptoe-standing knee flexion

S: Subject barefoot, standing tip-toe on one foot facing wall. Slight support from fingertips against wall in front of subject. P: Instructions: “Bend your knee slowly about this deep (demonstrating approx. 70º of knee flexion) without lowering the heel. Five repetitions.” Examiner standing behind and then beside subject.

Test D. Half-kneeling position: rising up from “half-kneeling”

S: Subject, without shoes on a mat, “half-kneeling” supported by right knee and with toes of right foot bent and on the mat (right hip in full extension, head and trunk vertical). Left foot placed in front of right foot on the mat (left knee and hip at about 90° of flexion). Body weight on right leg. P: Instructions: “Rise slowly with your body weight on the hind leg until knees are fully extended. Return to initial position. Five times on each leg.” To emphasize that the body weight should be placed on the hind leg, Examiner gives this instruction every time subject rises up. Examiner observing subject from behind and from the side.

Test E. Standing on one leg: knee flexion–extension

S: Subject standing on right foot beside a bench with left leg slightly raised from the floor, fingertips of left hand providing slight balance support on bench. P: Instructions: “Bend your right leg (demonstrating approx. 70° of knee flexion) and rise five times. Turn around and repeat the procedure on the left leg.” Examiner standing in front of and beside subject.

Test F. One-leg-standing: bouncing on a trampoline

S: Subject one-leg-standing on right foot on a trampoline close to wall, left side turned to wall, slight support from fingertips of left (then right) hand against wall. Left leg slightly elevated in hip and knee flexion. P: Instructions: “Bounce hard (but without leaving the trampoline with the supporting foot, in other words: do not jump and do no heel-ups) for about 20 s. Turn around and repeat on the left leg.” Examiner standing in front of and beside subject.

Test G. Forward lunge: forward lunge from stairs

S: Subject standing with shoes, on first step of a staircase (about 15 cm high). P: Instructions: “Take a long stride out onto the floor (about 80 cm from the step) with the right leg and land on the right foot with about 90° of flexion in the right knee (called “stride” in protocol), while the left foot remains on the step. Remain in this position for a moment, then return to the step with support mainly on the left leg (called “return” in protocol). Do this slowly, alternating the right and the left legs, five times on each side.” Examiner standing in front of and beside subject observing both the “stride” and the “return”.

Test H. Backwards walking: walking backwards on a treadmill

S: Subject walking backwards on treadmill at a rate of 25 min/km, barefoot with hands placed on top of the head, elbows pointing out sideways. (Practice for about 1 minute before the test was allowed.) P: Instructions: “Walk backwards for about 2 min.” Examiner standing in front of, beside and behind subject.

Test J. Mini-squat

S: Subject standing barefoot with feet a good hip-width apart. P: Instructions: “Bend your knees as if you were going to squat (minimum 90° of knee flexion), and rise up again five times”. Examiner standing in front of subject.

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Trulsson, A., Garwicz, M. & Ageberg, E. Postural orientation in subjects with anterior cruciate ligament injury: development and first evaluation of a new observational test battery. Knee Surg Sports Traumatol Arthrosc 18, 814–823 (2010). https://doi.org/10.1007/s00167-009-0959-x

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