title: Influence of patellar position on the knee extensor mechanism in normal and crouched walking.
abstract: Patella alta is common in cerebral palsy, especially in patients with crouch gait. Correction of patella alta has been advocated in the treatment of crouch, however the appropriate degree of correction and the implications for knee extensor function remain unclear. Therefore, the goal of this study was to assess the impact of patellar position on quadriceps and patellar tendon forces during normal and crouch gait. To this end, a lower extremity musculoskeletal model with a novel 12 degree of freedom knee joint was used to simulate normal gait in a healthy child, as well as mild (23 deg min knee flexion in stance), moderate (41 deg), and severe (67 deg) crouch gait in three children with cerebral palsy. The simulations revealed that quadriceps and patellar tendon forces increase dramatically with crouch, and are modulated by patellar position. For example with a normal patellar tendon position, peak patellar tendon forces were 0.7 times body weight in normal walking, but reached 2.2, 3.2 and 5.4 times body weight in mild, moderate and severe crouch. Moderate patella alta acted to reduce quadriceps and patellar tendon loads in crouch gait, due to an enhancement of the patellar tendon moment arms with alta in a flexed knee. In contrast, patella baja reduced the patellar tendon moment arm in a flexed knee and thus induced an increase in the patellar tendon loads needed to walk in crouch. Functionally, these results suggest that patella baja could also compromise knee extensor function for other flexed knee activities such as chair rise and stair climbing. The findings are important to consider when using surgical approaches for correcting patella alta in children who exhibit crouch gait patterns.
authors.affiliation: Department of Biomedical Engineering, University of Wisconsin-Madison, USA.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Lenhart
authors.affiliation: Department of Mechanical Engineering, University of Wisconsin-Madison, USA.
authors.forename: Scott C E
authors.initials: SC
authors.lastname: Brandon
authors.affiliation: Department of Mechanical Engineering, University of Wisconsin-Madison, USA.
authors.forename: Colin R
authors.initials: CR
authors.lastname: Smith
authors.affiliation: Gillette Children׳s Specialty Healthcare, USA; University of Minnesota - Twin Cities, Department of Orthopaedic Surgery, USA.
authors.forename: Tom F
authors.initials: TF
authors.lastname: Novacheck
authors.affiliation: Gillette Children׳s Specialty Healthcare, USA; University of Minnesota - Twin Cities, Department of Orthopaedic Surgery, USA.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Schwartz
authors.affiliation: Department of Biomedical Engineering, University of Wisconsin-Madison, USA; Department of Mechanical Engineering, University of Wisconsin-Madison, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, USA. Electronic address: dgthelen@wisc.edu.
authors.forename: Darryl G
authors.initials: DG
authors.lastname: Thelen
mesh_terms: D000293:Adolescent; D000328:Adult; D002547:Cerebral Palsy / Q000503:physiopathology*; D002648:Child; D005260:Female; D005684:Gait / Q000502:physiology*; D020233:Gait Disorders, Neurologic / Q000503:physiopathology*; D006801:Humans; D007719:Knee Joint / Q000502:physiology*; D008954:Models, Biological; D010329:Patella / Q000502:physiology*; D017847:Patellar Ligament / Q000502:physiology; D052097:Quadriceps Muscle / Q000502:physiology; D055815:Young Adult
keywords: Cerebral palsy; Knee extensor; Moment arm; Patella alta; Patella baja; Patella position