Patellofemoral joint and Achilles tendon loads during overground and treadmill running Richard W. Willy, PhD, PT, OCS1, Lisa Halsey, DPT1, Andrew Hayek, DPT 1, Holly n. Johnson, BS1, John D. Willson, PhD, PT1 o missi er p out 1Department of Physical Therapy, East Carolina University, Greenville, NC, USA. h wit es us er h Key words: running, patellofemoral joint, Achilles tendon, biomechanics ot o N y. nl o use Compliance with Ethical Standards: al n o pers The authors have no declared conflicts of interest and there are no disclosures of or F Melbourne - Faculties on June 15, 2016. Physical Therapy®. All rights reserved. ptprheraeosre ftreicaesirspscuaiholnt nspt saroo lp ftr ortehicolaiosrt l it poowrn eaesssnhe riaopnplstl pm swrteouitnvdhety cdi.no W bmthyrp iisttaht einenni veE aesans osdtitrg vCmaeatairorbnonauli.lfn aPcacor itUnousrnr eeitvornse ti rnwwsiithatiyaos t Hiomoubnamt ayo/aifnw nteih ldSli s buf resbotnjumeedcf yitats ,lf l rthoem ® y of orts Research Board. Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp CRADCsoieocsplrhlireasaegtrrastedmnp oWtoe fPnn iAltrdl yoloil finfee gPds s haHoyuerst aihcloathlr :TS hceiernacpeys East Carolina University Greenville, NC 27834 Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 1 Patellofemoral joint and Achilles tendon loads during overground and treadmill running n. missio Compliance with Ethical Standards: er p ut The authors have no declared conflicts of interest and there are no disclosures of o h wit uses professional relationships with companies or manufacturers who may/will benefit from er h ot No the results of this present study. Written and verbal consent was obtained from all y. nl o e us participants prior to enrollment in this investigation. Prior to initiation of this study, the al n o ers or p research protocol was approved by the East Carolina University Human Subjects F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. Research Board. MelboPhysic ® y of orts Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 2 Abstract 1 Study design: Level 4: Controlled laboratory study. 2 Background: Little is known regarding potential differences between treadmill and 3 overground running in regards to patellofemoral joint and Achilles tendon loading n. o missi er 4 characteristics. p ut o h wit uses 5 Objectives: We sought to compare measures of loading to the patellofemoral joint and er h ot No 6 Achilles tendon across treadmill and overground running in healthy, uninjured runners. y. nl o e us al 7 Methods: Eighteen healthy runners ran at their self-selected speed on an instrumented n o ers p For 8 treadmill and overground while three-dimensional running mechanics were sampled. A urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. 11019 mpeeaurcs h1c ukclioolonsmkdeietliteoetnra. l o Dmf acootdane tlwi ndeueroreiuv sae ndrua pnlyenzaienkdg l ofvoairad ,t hpreaa tiepre aodtfe llTolo-atfeedsmintsgo raaannl djdo ienPste taiamnrsadot eAnd’cs hc icullomersru etlaelatnitvdioeon nlso faotodr MelboPhysic 12 detect differences and assess relationships, respectively, between the two running ® y of orts Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp 1111134567 mRf1po eeerka sidtlkhuoiu elmtAms epc:s teh e.Na ilrlko eo, s dft hicftfeeoe nnrrdetainonteunc eo ofsufo sr(lo cprae>ud 0n(i.nnp0ig<n5,0g) o..w0 rH0 eeo1rsew)t, i femo1vua5ent.re6d, d% tbr ec eaugtwdmremeuaeiltlanel t rrit vurleeno anapdidnamigtnei gllrll e oarsfaneutdmlet e ooodvrfa e inlrA g jo2croih1nui.tl5l nes%dstr regtuesrnesnn adpitnoeegnrr 18 force (p<0.001) and 14.2% greater estimated cumulative Achilles tendon force per 1 19 kilometer of continuous running (p<0.001) compared with overground running. There 20 were strong (r>0.70) and moderate agreements (r>0.50) for most patellofemoral joint 21 and Achilles measures, respectively, between treadmill and overground running. Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 3 22 Conclusions: No differences were observed in loading characteristics to the 23 patellofemoral joint between running mediums, yet treadmill running resulted in greater 24 Achilles tendon loading compared with overground running, Future investigations 25 should determine if sudden bouts of treadmill running places the Achilles tendon at risk n. o missi 26 for mechanical overload in runners who habitually train overground. er p ut o h wit 27 Key words: Knee, ankle, biomechanics, musculoskeletal model es us er h ot No 28 y. nl o e us al n o ers p or F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. MelboPhysic ® y of orts Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 4 29 Introduction 30 The patellofemoral joint and Achilles tendon are among the most common sites of 31 injuries sustained by runners. More specifically, patellofemoral pain and Achilles n. 32 tendinopathy represents up to 25% and 9.5% of all running injuries, respectively. 31, 46 o missi er 33 As a result of the high prevalence associated with these injuries, it is not surprising that p ut o h wit 34 individuals with these injuries make up a large portion of patients in sports medicine es us other 35 clinics.15, 35 o N y. nl o e us 36 Factors previously related to patellofemoral pain and Achilles tendinopathy in runners al n o ers or p 37 include injury history, age, strength deficits, training errors, structural issues, biological F Melbourne - Faculties on June 15, 2016. Physical Therapy®. All rights reserved. 33448901 sabraeniotxaem t)o eaamcnnhdidca anibnl iic osaatm rlh ueliocgctahhudlarysen rsi(ec i.padeelu. ,tr ioiptnivvegeea r krlmou lanoadnaniidnnnsegg)r. 1a(i2si,r. ee1c. 9,go, cem3un2pme, ler3uax3ll,a lyat3i 7vna,e dp 3 pl9oml,i aeu5dd4lts iaf)Ba tt cioaoe matrearetdpicc.ih duSa larnparie tcsecat irl(f uiic.cleaot.lua,l yrdleo,i nsalga da rignnoedgf Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at The University of Copyright © ${year} Journal of Orthopaedic & Sports 4444423456 trsTceahornteonedauv odaeldnmnn sdaiie l lltlntsh obt r,teo aap ulrc aegcor huntic mcstohuidumelaela mrrctleiyoovd uned rip nusllo erabia nciodoegfsm iainoen cfcr ulhtethnramae.n1i en,i pcn9inaa,t 1gtl e2wi nll eaovTanefhetdshum teisgror,ea rmohatiraloe bnjwaoislsihin tuoeatr fnte cito sahon repo tsitflsia eopeg nsetetstair n uakfgoc nsltrodu. a orAeTducssrtdeh., oaitlhlodeerms riltolulesann dndaiinonrgeng 47 are restricted. Treadmills are also routinely used in clinical gait analysis and gait 48 retraining programs due to the ability to evaluate and retrain running mechanics in a 49 controlled environment.4, 13, 43 Further, treadmills are often a fixture in training programs 50 and return to running programs after injury to the patellofemoral joint or Achilles tendon. Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 5 51 Instrumented treadmills are now commonly used in biomechanical studies of ankle and 52 knee mechanics during running.8, 29, 30, 40, 52 In particular, instrumented treadmills enable 53 the study of repetitive gait cycles and facilitate more in-depth analyses, such as exertion 54 and gait modification studies.23, 51 Despite their common use in either of these n. o missi 55 applications, little is known regarding the potential differences of loading to the er p ut ho 56 patellofemoral joint and the Achilles tendon during overground and treadmill running. wit es us er h ot 57 Seminal biomechanical comparisons between treadmill and overground running o N y. nl e o 58 suggest that these running mediums have largely similar knee and ankle kinematics, us al n erso 59 particularly in the sagittal plane.20, 40 However, potential differences in joint kinetics exist, p or F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. 66660123 sareuunxngtdeng niAenscsgoht irhni llagems sto h bmtaeetene tndnhto e rnrece pob aomerrteptwe adedrie eftfndoe rorewevnisetchureg ltsr oo iinvnu e nalrodgna r aodanuipndnpg dr toc rexhriauamdnraamnctienitlellg yrr. iu4s20nt 7inc% isnT golho.fe wtF heoperre ppainaeksta etkkall nnoinecfeteeem ,r neotraxreatla elk dnjnomseionielrtl ® y of Melboorts Physic 64 moment likely closely relates to peak quadriceps force 2 which in turn greatly influences Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp 6666656789 pta(arpalreseataoeatde l)olml olcobficefelleu mtmwrru.o5eonr earTnanlih ln jeogtjrroi,ene2inat0f o,td r r4eme0sa ,ti acrlilett i scaoissonn =rd urf eonposrcacvpleeteoea.rn5lgrl2do r ioiff ne Hutgmhno edowrre reeadr vulua encrjronet,i ii onnadntgsi f . fr ikeneCnr aeeopcnenatci vtoefeelnelsrl oxs iffienooel rnympc, ae omtt/rhepaaelayll o t cepafeolellsmonaoftkoea brmcpaet oll a alrjenoarestilna satcr doswfulnteorrtexuiansolcdgsrt 70 moment and eccentric ankle joint power may be as much as 14% and 16% higher, 71 respectively, during treadmill running 40 suggesting greater Achilles tendon demands. 72 Previous work has also investigated temporospatial differences between treadmill and 73 overground running that can have an important effect on cumulative loading for the Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 6 74 patellofemoral joint and Achilles tendon. Compared with overground, runners tend to 75 adopt 1-5% shorter step length during treadmill running.18, 40 This potentially important 76 temporospatial difference may have consequences for patellofemoral joint and Achilles 77 tendon loading. Firstly, a shorter step length during treadmill running may indicate a n. o missi 78 shorter stance phase which may, in turn, result in a greater loading rate of the er p ut ho 79 patellofemoral joint and Achilles tendon if peak loads are of the same or greater wit es er us 80 magnitude as overground running. Secondly, the shorter step length associated with h ot o N y. 81 treadmill running may result in a greater number of steps i.e., loading cycles, to cover a nl o e us al 82 given distance which may in turn increase cumulative loading on the patellofemoral joint n o ers p or 83 and Achilles tendon during a sustained run. F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. 888456 Tloovhaeedr ignprguo ruponofds etrh uoenf n tipnhagist.e slDlotuufedemy t oow raaasl r etjoodi unacts esaden skdsn eptheee ae kxA tleocnhasidlolser,s mratoetemn doeofn ntl,o awddueirn ihngyg pa ontrtdhe eacsduimmzeiuldl la tathinvadet ® y of Melboorts Physic 87 treadmill running would result in reduced peak patellofemoral joint stress and Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp 8899989012 pbhlMoaeyaept dtegohilrnlteoohgadfee twssemi orz oeuArdladc lh rtihjelolaseinuts tl tgt sedrtenuraedetso etsnor llaoco uaarmdedidinunuglgac teariavdnet des .tpl eoCapato delneilnlvnogegfe rtrshmae tdoelyur ,adr ilwun rgjeoin itnhgrety taprsedotamrtehdiselmls sr iiulzla nernnuddin n tnhgAia.nc t gh .ti lhlFeeisnre at lewlyno,d uwoledn 93 Prior to study initiation, the research protocol was approved by the East Carolina 94 University Institutional Human Subjects Research Board. An a priori sample size 95 estimate was conducted to determine the number of participants necessary to detect Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 7 96 differences between conditions. Using α = 0.05, β = 0.2, and means and variability of 97 the peak knee extensor and plantarflexor moments between running overground and on 98 a treadmill from Riley and colleagues40, 18 participants were conservatively determined 99 to be necessary to adequately power this study. For this investigation, we recruited 18 n. o missi 100 recreational runners (9 males, 9 females) from a large university and area running er p ut ho 101 clubs. wit es us er h ot 102 All participants provided written and verbal consent prior to enrollment. In order to o N y. nl e o 103 qualify, all participants were required to be habitual runners (defined as at least 10 us al n erso 104 km/week for at least the previous 6 months), free of any lower extremity surgeries and p or F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. 111100005678 iaimnngjteureocr yhdto-auf rncleieimceds i ft.bo h3yr8 e aatTte ghrleroeeagraesetftneo terrh eiaet,yg p oeirnn er layvb iniovoguomeslu.e 13nc6 ,th me4a1e onCrnsicot shwm shaf.o onPr dtaw wrAetiicrtchehip itlcarleoensmat sdtf eomwnrietldalr oberunl eln im pnwriiontietpghde c trtratoeine a1 sad8 fmt-fh3eia5lclt t rymrueunaannyrnsi ni bngoeg,f ® y of Melboorts Physic 109 defined as a score of at least “8” on a visual analog scale (“0” and “10” corresponding to Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp 111111111101234 cW(cF“ooirfhumhtyinol-penrsl tiei nnxoto gefr t ler yeuat xrnnuopn nreienecrfcroileselmu ncisncftoii eovtrh”ent)ai / smewb xilaanecsrv lkuv eaeesslrirstossiog nuw a cscteo irocrliletnoee .mcra i tofpefnildxe,.e t cePdol ylteno atc intsoheume os fuboesirelta a intTbevAlreoaB,ll v LrleoEemws 1pee enrfo cte rtii xnvdt ereeelmynm)do,i utgwierraaesnpr, echp eieec lrsnvu riosno fnl aletinhndged. 115 trunk of each participant. Static calibration and dynamic hip trials28 were collected. The 116 pelvis coordinate system was defined by markers placed on the midline of the iliac 117 crests and the greater trochanters. The thigh coordinate system was defined proximally 118 by the calculated hip joint center from the dynamic hip trial and distally by the femoral Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 8 119 condyles. The shank coordinate system was defined proximally by the tibial condyles 120 and distally by the malleoli. Finally, the foot was defined proximally by the malleoli and 121 distally by the 1st and 5th metatarsal heads and the distal aspect of the shoe. Tracking 122 markers consisted of markers placed on the anterior superior iliac spines and shell- n. o missi 123 mounted clusters on the sacrum, posterolateral aspect of the thigh and shank, and a er p ut ho 124 cluster of three markers on the rearfoot. This is a common marker set configuration and wit es er us 125 was similar to the marker set used by Fellin et al. (2010), a study of comparison for the h ot o y. N 126 present investigation.20 nl o e us al n erso 127 After a 6-minute treadmill accommodation period,34 3-dimensional running mechanics p or F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. 111122338901 wPdeusaetrrraitenibc gliip sstaahhnmeetd sp, ml ewbdieda rdsefleoe dcr u oeo1f dn0a t toshs eetcac honpondaodarsstreid c itaphttrai asni ents’aispnc eghfee drepu dbanbar.at siccTeikhpd,ea o ndnstu’ esrpil nfe-sgsrce eeltlfhep-sectiet oelfnedin c oatreflu dtn4h n eriminur gnirn nuusinntpnegeis ne gsdop fpe waethacdees. ® y of Melboorts Physic 132 treadmill accommodation period. Ground reaction forces and marker trajectories were Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp 111113333334567 saSwSanWoamdksE k pp2i) l,ee0 Crdr0feo o srarHpmpt .ze,e1 cd0Ybti 0yvou0 eks aloiynH h.g z1aP 0mabr- icadyoa ,irg tmhJittoeaae plrs aitanta unscmd)thr.y ouo tmmiinToeeihntnite aet cterit aodrepen vtta,eur detrrrymeae d0ailsml.d 2ymirs lumlt inel(l/ Bnmssieenp crge(t Qe uectpdur,i a atcoWllya s4wloiib.sra0tr hs amCi tninoo/gsornt.pot (.dn,Hl ou, TGnrOi-gno5hegt5hir o0 er,0tu nh,nUb anOuSnirnn Agg5o), 138 minutes of sustained running and an approximately 10-minute rest period was provided 139 to each runner between the end of treadmill testing and initiation of overground testing 140 to minimize fatigue. Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 9 141 Next, 3-D overground running mechanics were sampled as runners traversed a 25- 142 meter runway at their same self-selected running speed (±3%) used during the treadmill 143 running. Each runner practiced execution of the overground trials for several minutes to 144 accommodate to the overground collection procedures, including establishment of n. o missi 145 running speed and runway starting position. Displacement of a single marker attached er p ut ho 146 to the sacrum has previously been demonstrated to correspond to the displacement of a wit es er us 147 runner’s estimated center of mass.21, 22 Therefore, we tracked the anterior velocity of a h ot o N y. 148 sacral marker in real-time to measure running speed as the runner traversed force nl o e us al 149 plates flush with the runway floor (AMTI, Watertown, Mass, USA). In post-processing, n o ers p or 150 this method for tracking overground running velocity was highly correlated to the F urne - Faculties on June 15, 2016. al Therapy®. All rights reserved. 111555123 avwenitlthoe craiiot yrro ovofet ltmohceei tasyna o csfrq atuhl aemr erau renkrenrore rra=’sn 0de. s1et simmtim/asteaectde) .dc A ecnneytne ttrer iroa flos mf tmhaasatss f se(:cl loP orerueatslrasidtoieon n’ts hb ere= vt we0el.o9ec6ni t pya <rna0ten.0rg0ioe1r, MelboPhysic 154 in which the participant was visibly changing velocity in the capture volume or when the ® y of orts Journal of Orthopaedic & Sports Physical Therapy Downloaded from www.jospt.org at The Universit Copyright © ${year} Journal of Orthopaedic & Sp 111111555556567890 ftm7skor aiiMnaarmcelrasekmer e ki pnadpel ta aritec htrtefsarifssa ema jcmewnetcsdetate ronokerrnsin nie te aeatsrhrt s igwe(c Qe stamht,use oraa destglh eysbnasp yituiets uttdc)ihdl itifaeizefven eseprdd laeoy grnf)dt .rtis uc o egriupigannamigtdn evttr ehnewletaoea ccrlt teriviteo ieedanlsido s fmccoaiarnticilredlde s tesfr,oi dawjro.cl eiTen(r2h tep 0e mls0 arao taemHmt izoptea nlnearagtdnslee d wta ifnn1iotgdh0r 0ectph0xaoe cnwH l ueehzdxra isafnvo.c3gert, 161 The order of testing (treadmill first followed by overground testing) was chosen to 162 determine each participant’s safe self-selected running speed for the treadmill trials. In 163 testing during protocol development, pilot subjects tended to self-select a running speed Overground and treadmill comparison of patellofemoral joint and Achilles tendon loads, Page 10
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