P. Westblad

Effects of fatigue and load variation on metatarsal deformation measured in vivo during barefoot walking

This in vivo study presents information to assist in the understanding of metatarsal stress fracture etiology. The aims were (a) to provide a fundamental description of loading patterns of the second metatarsal (MTII) during barefoot walking, and (b) to investigate the hypothesis that MTII dorsal strain increases with fatigue and external carrying load. Dorsal MTII strain was measured in vivo under local anaesthetic with an instrumented staple in eight subjects. Experimental conditions were external loading with a 20 kg backpack and pre- and post-fatigue. M. flexor digitorum longus electromyography tentatively indicated fatigue after an extended walking treatment. A reproducible, cyclic temporal pattern of dorsal MTII surface deformation was described. Mean peak compression and tension strains in unloaded barefoot walking were -1534 +/- 636 and 363 +/- 359 muepsilon, respectively. Mean peak compression strain rate (SR) was -4165 +/- 1233 muepsilon/s. Compression strain increased significantly (alpha=0.05) both with the addition of the backpack and post-fatigue while maximum tension decreased significantly post-fatigue. SR increased significantly with the addition of the backpack. The highest plantar force time integrals were recorded underneath the heads of metatarsals II-V for all conditions (1561Ns pre-fatigue, without backpack; 2123Ns post, with). EMG and plantar pressure data presented a comprehensive description of biomechanical parameters influencing dorsal MTII deformation and alterations in strain following two experimental conditions were suggested as contributing factors in the pathogenesis of metatarsal stress fractures.

Differences in Ankle-Joint Complex Motion During the Stance Phase of Walking as Measured by Superficial and Bone-Anchored Markers

Bones of the ankle-joint complex are difficult to represent with superficial markers and an invasive approach is required to quantify skin movement artifact. Three-dimensional coordinates during gait were first calculated from sets of three superficial markers located on both the lower leg and heel. Intracortical pins equipped with external marker arrays were subsequently inserted in the tibia, talus and calcaneus for further trials. Tibiocalcaneal and talocalcaneal joint helical axis component rotations were calculated. Intersubject motion patterns were comparable. Root mean square (RMS) differences were chosen to describe discrepancies between temporal intracortical pin and superficial marker curves. Results for the tibiocalcaneal rotations inversion / eversion, plantarflexion / dorsiflexion and abduction / adduction were 2.5°, 1.7° and 2.8° respectively. Inversion / eversion about the talocalcaneal joint showed an RMS difference of 2.1°. A systematic over- or underestimation of superficial relative to bone-anchored markers could not be determined.

Local Bone Deformation at Two Predominant Sites for Stress Fractures of the Tibia: An In Vivo Study

Local bone deformation was registered at two predominant injury sites for tibial stress fractures in a healthy female volunteer. Two instrumented strain gauge staples were inserted under local anesthesia to the anterior middiaphysis (AM) and to the posteromedial part of the distal tibia (PD). Calibration and reliability of the instrumented staple system have previously been demonstrated in vitro. Concomitant ground reaction forces were registered with a Kistler force plate. Studying peak values, it was shown that during a voluntary 30-cm forward jump, PD deformation was greater during forefoot landing (2700–4200 microstrain) than during a heel strike landing (1200–1900 microstrain) and also compared with the concomitant AM deformation under both above testing conditions (1300–1900 microstrain). The stance phase during walking resulted in PD deformation of 950 microstrain, whereas the concomitant AM deformation was 334 microstrain. The greatest AM deformation (mean, 2128 microstrain) was registered during ground contact after a voluntary vertical drop from a height of 45 cm, concomitant with a PD deformation of 436 microstrain. These data are the first to show different local deformations at various sites of the tibia in vivo. The PD deformation was larger than previously noted from other parts of the tibia, whereas the middiaphysis data are consistent with other reports. The results may support the clinical assumption of different etiologies for stress fractures at these predominant sites.

A comparison of external plantar loading and in vivo local metatarsal deformation wearing two different military boots

The introduction of the M90 boot with a more flexible outer sole to military recruits in Sweden was accompanied by an increase in second metatarsal stress fractures. This study compared the new boot with the previous, stiffer model. A combination of external plantar pressure measurement (two subjects) and an in vivo measurement of dorsal metatarsal strain (six subjects) using strain gauge instrumented staples was implemented. Walking in both boot models resulted in increased plantar pressure under the heads of the lesser metatarsals and generally decreased loading under the remainder of the foot. Dorsal metatarsal tension increased for subjects wearing the new boot throughout a walking protocol.

A Study of Intrinsic Factors in Patients with Stress Fractures of the Tibia

We aimed to study intrinsic factors in 29 consecutive patients with well-documented unilateral stress fractures of the tibia. Anthropometry, range of motion, isokinetic plantar flexor muscle performance, and gait pattern were analyzed. The uninjured leg served as the control. A reference group of 30 uninjured subjects was compared regarding gait pattern. Anterior stress fractures of the tibia (N = 10) were localized in the push-off/ landing leg in 9/10 athletes, but were similarly distributed between legs in posteromedial injuries (N = 19). Ten (30%) of the stress fracture subjects had bilateral high foot arches, similar to those found in the reference group. There were no other systematic differences in anthropometry, range of motion, gait pattern, or isokinetic plantar flexor muscle peak torque and endurance between injured and uninjured legs. No other differences were found between anterior and posteromedial stress fractures. We conclude that anterior stress fractures of the tibia occur mainly in the push-off/landing leg in athletes. Within the limitations of our protocol, no registered intrinsic factor was found to be directly associated with the occurrence of a stress fracture of the tibia.

Early influence of an ankle sprain on objective measures of ankle joint function. A prospective randomised study of ankle brace treatment.

Abstract The purpose of this study was to analyse objective modalities of ankle joint function after an acute ankle sprain and to see whether treatment with an air-cushioned ankle brace could enhance the restoration of function compared with a traditionally used compression bandage. The study included 73 consecutive patients between 15 and 55 years of age with an acute grade II or III ankle sprain, who sought medical care within 24 h of the time of injury. Patients with recurrent sprain were excluded. The patients were allocated at random to treatment with compression bandage or an air-cushioned ankle brace (Air-Stirrup, Aircast). The regimen included early motion and weight-bearing in both groups. The patients were examined initially within 24 h, after 3–5 days, 2, 4 and 10 weeks after the injury by the following tests: clinical examination including range of motion, recording of postural sway by stabilometry, joint position sense test, isokinetic eversion-inversion muscle torques and figure-of-eight running. A decreased active range of motion in eversion-inversion was observed during the entire follow-up period. Increased postural sway was registered when standing on the injured foot up to 4 weeks after the injury, as were a deficit in evertor muscle peak torque and an evertor-invertor muscle imbalance compared with the uninjured side. Women demonstrated a greater impairment in postural sway than men. A longer curve running time with the injured ankle at the outside of the curve was noted at the 10-week follow-up. With the exception of running in a figure of eight, these measures were not influenced by treatment with a semi-rigid ankle brace. The methods used in the present study are well suited for further studies of objective modalities of ankle joint function, with the possible exception of the joint position sense test.

An experimental in vivo method for analysis of local deformation on tibia, with simultaneous measures of ground reaction forces, lower extremity muscle activity and joint motion.

This paper presents the pilot procedures of a new in vivo experimental method for measures of local bone deformation on tibia. The tibia transducer consists of a strain gauge mounted on a surgical staple, and was designed to measure local bone deformation. Pilot measurements were undertaken during two standardized conditions of forefoot and heel landing in seven healthy volunteers. Implantation of two tibia force transducers on tibia were preformed under local anaesthesia. The local peak tibia deformation occurred at 20–42 ms (median) after ground contact, and was up to eight times higher during stance phase loading compared with standing still on one leg. Ground reaction forces, muscle activation patterns and kinematics and were registered stimulataneously, and were used to validate that the observed local deformation on tibia occurred under controlled and clinically relevant conditions. The new method may be used for investigating local deformation within various bone structures of the lower extremity. There are further methodological issues to address before major clinical interpretations may be concluded. In order to verify that the strain gauge transducer system was valid, a controlled displacement of the staple shanks was performed with a micrometer, and showed a linear relationship between applied deformation and strain gauge response (r= 0.97–0.99). In addition, a linear relationship was found between externally applied static forces and strain gauge response in a four‐point bending cadaver system (r= 0.96–0.98).

Aerobic and anaerobic work capacities and leg muscle characteristics in elite orienteers

Aerobic and anaerobic work capacities, leg muscle structure and metabolic characteristics of m. vastus lateralis (NT), m. rectus femoris (RG) and mm. gastrocnemii (NT and RG) were analysed in five male and seven female elite orienteers from the Swedish National team (NT) and a reference group (RG) of eight male and 10 female upcoming orienteers, all in optimal shape at the end of a competitive season. Maximal oxygen uptake was 78.4 mlikgimin for NT men (range 75–81) and 67.8 ml/kg/min for NT women (range 62–71), for both groups significantly higher (P<0.001) than for RG. Maximal serum lactate was 13.3 mmol/l for NT men (range 10–17) and 11.7 mmol/l for NT women (range 8.4–14), which did not differ from RG. No significant correlation was found between maximal oxygen uptake and maximal serum lactate. For NT females only maximal oxygen uptake was significantly related to running economy (P<0.01). Muscle biopsies showed a high content of type I fibres in m. vastus lateralis as well as in m. gastrocnemius mediale. M. vastus lateralis (NT) had a higher proportion of type I fibres, capillaries per fibre as well as CS, HAD and LDH 1–2 enzymes compared with m. rectus femoris (RG) (P<0.01–<0.001), the latter muscle showing a more anaerobic profile. NT males and females had a higher metabolic potential in m. gastrocnemius mediale than RG (P<0.001). Our results reflect an obligate high and narrow range of aerobic and anaerobic work capacities for successful performance in international elite orienteering. It remains to be shown how these laboratory data are related to individual performance in authentic orienteering competitions.

Muscle strength and endurance after surgery for primary hyperparathyroidism

OBJECTIVE To evaluate the effect of surgery on muscular strength and endurance in patients with primary hyperparathyroidism (HPT). DESIGN Prospective open study. SETTING University hospital, Sweden. SUBJECTS Nine patients undergoing HPT surgery and nine matched patients undergoing thyroid resection who acted as controls. INTERVENTIONS Concentric and eccentric endurance was evaluated with a test comprising 100 repeatedly executed muscle action at 90 degrees.s-1. Blood samples obtained before and after operation were analysed for calcium, phosphate, thyroid stimulating hormone (TSH), and parathyroid hormone (PTH) concentrations. MAIN OUTCOME MEASURES Peak torque during maximum voluntary concentric and eccentric muscle actions at 90 degrees.s-1 before, three months and one year after operation. RESULTS There were no differences in concentric and eccentric peak torque before and after operation either within or between groups. Concentric and eccentric endurance were similar in the HPT group and controls before as well as after operation. The return of calcium and PTH concentrations to their reference ranges after parathyroidectomy did not correlate with changes in concentric and eccentric peak torque. CONCLUSIONS The subjective improvement in muscle endurance which is often encountered in patients with HPT after operation is not associated with an objective increase in muscle strength or endurance as measured by isokinetic muscle performance.

The reliability and validity of an instrumented staple system for in vivo measurement of local bone deformation

We recently presented a pilot study using an instrumented staple system for measurein in vivo local deformation on tibia. Methodological development has now proceeded in vitro. Consecutively, we performed 1. a sheep bone micrometer study, 2. a sheep bone four‐point bending test and 3. a pig bone four‐point and three‐point bending test. This was done in order to secure a standardized application of the staple, to analyze the interaction of the bone and the staple and to secure calibration and reliability of the system to be used in vivo. With refernce to the above studies: 1. There was a linear relationship (r=0.998) between the applied deformation of the bone and the measured deformation of the staple. ICC values ranged from 0.866 to 0.997. 2. An excellent intra‐test reliability as well as linearity between staple measures and surface strain on the bone was observed (r=0.998). 3. The slope of regression lines (k) was min 7.2 and max 9.4. The results from this test are used for calibration of the instrumented staple. Great variations were found between tension and compression measurements. However, within each test the SD was negligible. We suggest that the instrumented staple system may be calibrated in vitro and validly used for in vivo measurement of local bone deformation.