title: Joint contact forces when minimizing the external knee adduction moment by gait modification: A computer simulation study.
abstract: OBJECTIVE
  Gait modification is often used to reduce the external knee adduction moment (KAM) in human walking, but the relationship between KAM reduction and changes in medial knee joint contact force (JCF) is not well established. Our purpose was to examine the limiting case of KAM-based gait modification: reducing the KAM as much as possible, and the resulting effects on JCF.
  
  
  METHODS
  We used musculoskeletal modeling to perform three optimal control simulations: normal walking, a modified gait that reduced the KAM as much as theoretically possible (Min(KAM) simulation), and a second modified gait that minimized the KAM plus the metabolic cost of transport (Min(KAM+CoT) simulation).
  
  
  RESULTS
  The two modified gaits both reduced the peak KAM from normal walking (-82% for Min(KAM) simulation, -74% for Min(KAM+CoT) simulation) by increasing trunk lean, toe-out, and step width, and reducing knee flexion. Even though the Min(KAM+CoT) simulation had the larger KAM, it had a greater reduction in peak medial JCF (-27%) than the Min(KAM) simulation (-15%) because it reduced the KAM using less knee muscle activity. These results were qualitatively robust to a sensitivity analysis of the knee joint model, but the magnitude of changes varied by an order of magnitude.
  
  
  CONCLUSIONS
  The results suggest that (i) gait modification can benefit from considering whole-body motion rather than single adjustments, (ii) accurate interpretation of KAM effects on medial JCF requires consideration of muscle forces, and (iii) subject-specific knee models are needed to accurately determine the magnitude of KAM reduction effects on JCF.
authors.affiliation: Department of Kinesiology, University of Maryland, College Park, MD, USA; Neuroscience & Cognitive Science Program, University of Maryland, College Park, MD, USA. Electronic address: rosshm@umd.edu.
authors.forename: Ross H
authors.initials: RH
authors.lastname: Miller
authors.affiliation: Department of Kinesiology, University of Maryland, College Park, MD, USA.
authors.forename: Aryeh Y
authors.initials: AY
authors.lastname: Esterson
authors.affiliation: Department of Kinesiology, University of Maryland, College Park, MD, USA; Neuroscience & Cognitive Science Program, University of Maryland, College Park, MD, USA; Fischell Bioengineering Graduate Program, University of Maryland, College Park, MD, USA; Department of Mechanical Engineering, Kyung Hee University, South Korea.
authors.forename: Jae Kun
authors.initials: JK
authors.lastname: Shim
mesh_terms: D001696:Biomechanical Phenomena; D003198:Computer Simulation; D005684:Gait / Q000502:physiology*; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology*; D020370:Osteoarthritis, Knee / Q000503:physiopathology*; D015203:Reproducibility of Results; D016138:Walking / Q000502:physiology*; D016474:Weight-Bearing / Q000502:physiology*
keywords: Gait modification; Joint contact force; Knee adduction moment; Minimization; Simulation