The effect of a knee brace on muscle forces during single-leg landings at two heights

doi:10.21203/rs.3.rs-1618261/v1

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The effect of a knee brace on muscle forces during single-leg landings at two heights

https://doi.org/10.21203/rs.3.rs-1618261/v1

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Background: The single-leg landing is one of the maneuvers that has been linked to non-contact ACL injuries, and knee braces have been shown to reduce ACL injury incidence. The purpose of this study was to determine whether a knee brace has an effect on muscle force during single-leg landings at two heights through musculoskeletal simulation.

Methods: 11 healthy male participants were recruited to complete single-leg landings at 30 cm and 45 cm between the braced and non-braced. We recorded trajectories and ground reaction force using an 8-camera motion capture system and a force platform. The captured data was imported into the generic musculoskeletal model (Gait2392) in OpenSim. Static optimization was used to calculate muscle forces.

Results: The gluteus minimus, rectus femoris, vastus medialis, vastus lateralis, vastus medialis medial gastrocnemius, lateral gartrocnemius, and soles muscle forces all showed statistically significant differences between the braced and non-braced. Simultaneously, increasing landing height significantly affected gluteus maximums, vastus medialis, and vastus intermedia muscle forces.

Conclusions: Our findings imply that the knee brace may be able to alter muscle forces in single-leg landings to prevent anterior cruciate ligament injury. Additionally, research demonstrates that people should avoid landing from heights due to the increased risk of knee injuries.

Single-leg landings

Knee brace

Musculoskeletal modeling

ACL injuries

Jumping and landing are the most common maneuvers in sports and are prone to non-contact injuries like anterior cruciate ligament (ACL) injuries [1–3]. Around 70% of ACL injuries occur in landing or sidestep cutting tasks [4]. Single-leg landings and double-leg landings are the two types of landings. Due to the lower knee flexion angles, single-leg landings are more prone to induce ACL injuries than double-leg landings [5, 6]. ACL injuries not only decrease an individual’s daily activities but also lead to higher risks of degenerative joint diseases [7].

Muscle forces are critical in preventing ACL injuries and maintaining knee stability. Regarding muscle forces, weak quadriceps are a risk factor for non-contact ACL injuries [8]. Similarly, soleus and hamstring coordination may offer additional support to reduce the risk of ACL injuries during single-leg landings [9]. In addition, some investigations have found that the gastrocnemius and soleus muscle (which stabilize the ankle joint) can also prevent ACL injuries [10, 11].

Studies have shown that knee braces are effective in reducing the risks of ACL injuries [12, 13]. Previous studies have shown that knee braces can influence the degree of activation of lower limb muscles. For example, surface electromyography (EMG) signals show that vastus lateralis and vastus medialis muscle are extensively active when wearing a knee brace in a survey of kicking [14]. In another study on squatting, the muscle activation level represented as the peak root means a square average of the surface EMG signal declined by around one-third [15]. It should be noted that surface EMG signal is limited as it cannot effectively detect the muscle located deeper. And surface EMG signal alone will not be able to offer us a complete and detailed blueprint of the activations of muscle involved. Compared to the employment of surface EMG signals to study muscle force, the simulation approach in the research can obtain more muscle force data of different parts in a non-invasive manner. However, the effects of knee braces on muscle force during single-leg landings have never been studied by simulation.

Therefore, the purpose of the study was to investigate the effects of wearing a knee brace on biomechanical performance during single-leg landings at two heights by simulation. Specifically, we hypothesized that wearing the knee brace can affect lower limb muscle forces. Regarding landing height, we hypothesized that muscle forces would be increased with the increase of landing height.

Participants

Eleven physically active male participants were recruited to conduct landing tasks(the sample size was set according to experience). None of the participants had a history of lower limb injuries at least six months before the study. All participants (age: 23.2 ± 2.5 years; height: 1.78 ± 0.34 m; mass: 74.2 ± 6.1 kg) were physically active in line with the international standard of physical activity guideline, which refers physically active lifestyle as exercising for at least 150 minutes with moderate-intensity or 75 minutes with vigorous-intensity every week in the past three months [16]. Informed consent was provided, and the Biological and Medical Ethics Committee of the Dalian University of Technology approved this study.

Instrumentation

In this study, we used the elastic knee brace of Ossur (~ 160g net weight), and it was authenticated by European Union certification and International Organization for Standardization certification. Two multifunctional boxes of heights 30cm and 45cm were employed. For motion analysis, an 8-camera motion capture system with a frequency of 100 Hz (Vicon Peak, Oxford Metrics Ltd, UK) was used to record three dimensions (3D) marker trajectories. Thirty-nine retro-reflective markers (25mm diameter) were attached to each person at the corresponding anatomical landmarks based on the Gait2392 model [17]. In addition, a force platform (AMTI, Advanced Mechanical Technology, Inc., Watertown, USA) was utilized synchronously to record ground reaction force (GRF) at a frequency of 1000 Hz. Kinematics and kinetic data were filtered by a zero phase-lag, fourth-order Butterworth filter with a cut-off frequency of 6 Hz.

Experiment Procedure

The Duration of a single-leg landing was defined as the interval starting from initial foot contact to maximum knee flexion [18]. Before the test, participants were told to conduct a 5 min warm-up (jogging) when arriving at the sports science lab. Then, details about the single-leg landing were explained to make them understand the form of the maneuver. Participants performed single-leg landing three times for each test condition using their dominant legs, defined as the limb that people prefer to kick a ball [19]. All participants used their right lower limbs to perform the task in this study. Experiments proceeded in four categories with two factors (height and knee brace). One participant completed one trial, and a 30-second break was given to avoid fatigue. A successful test was accepted if the participant stepped off the box in a stable landing posture without an upward and forward jumping motion [9]. Injuries are more likely to occur at peak GRF and maximum knee flexion during landings[18, 20].

Opensim Simulation

OpenSim 4.0, an open-source musculoskeletal simulation software [21] was run to obtain kinematics, kinetics, and muscle forces. Single-leg landing simulations were generated in OpenSim (Figure. 1). First, C3D files obtained from Vicon were transferred by MATLAB (The Mathworks Inc., Natick, MA) and were imported into the OpenSim. A musculoskeletal model named Gait2392 was established in the platform, which possesses eight segments(torso, pelvis, femurs, shanks, feet), 23 degrees of freedom and 92 musculoskeletal muscle, mainly in the lower limbs. A generic model of each participant was obtained through a running scale according to anthropological data captured in the lab [22–24]. Specifically, the dimension of each segment was scaled according to corresponding markers obtained from the static experiment captured in the lab, and their RMS error about the position of markers was restricted under 3cm. Then inverse kinematics was run to minimize the differences between experimental and virtual mark position through the least-squares method, and its RMS mark errors were limited to under 3.5cm [25]. Afterward, joint angles were obtained, a primary outcome measure for conducting the following steps. Inverse dynamics was run to obtain net joint torque using results from the last step (i.e., inverse kinematics) and GRF to solve a series of dynamic equations. In addition, a residual reduction algorithm was adopted to reduce residual force (applied to the pelvis) caused by the inconsistency between the force platform and kinematics data in the musculoskeletal model. Finally, static optimization predicted muscle forces (using the RRA results) with the objective function being the minimizes the sum of squared muscle activations [26].

Statistical analysis

The gluteus maximus, gluteus medius, gluteus minimus, rectus femoris, medial femoris, medial femoris, lateral gastrocnemius, lateral gastrocnemius, and soleus muscle were examined. The experimental data in the outcomes of this study were expressed as mean ± standard deviation (Means ± S.D). The muscle forces data was divided by each participant's body mass via Excel 2018, and two characteristic moments were selected based on previous literature reports that could both cause ACL injuries: the moment of peak GRF and the moment of maximum knee flexion. The retrieved data were stored and counted using SPSS 22.0 (SPSS Inc., Chicago, IL, USA) software. A two-way repeated measures ANOVA was utilized to assess if knee braces alter muscle force during single-leg landings at two heights through musculoskeletal simulation. With a significance level of 0.05. Final graphics were drawn using Prism 8.0.

Initially, we compared results with a previous study (Figure. 2) [27], and the similar patterns of quadriceps, hamstrings and gastrocnemius muscle activation indicate that the simulation results were reliable.

At peak GRF, there was no significant (p > 0.05) interaction between the individual lower limb muscle between the braced and non-braced (Table 1). There were significant (p < 0.05) differences between the vastus medialis, vastus intermedialis, vastus lateralis, medial gastrocnemius, lateral gastrocnemius, and soleus muscle with the braced (Table 1). The gluteus maximus muscle was significantly (p < 0.05) effected with the 45 compared to 30cm (Table 1).

At maximum knee flexion, there was no significant (p > 0.05) interaction between the braced and non-braced and landing height for any lower limb muscle (Table 2). There were significant (p < 0.05) differences between the gluteus minimus, rectus femoris, vastus intermedius, vastus medialis, vastus lateralis, medial gastrocnemius and lateral gastrocnemius muscle with the braced (P < 0.05), and the forces of these muscles were significantly (P < 0.05) greater with the braced than non-braced except the medial gastrocnemius (Table 2). The vastus medialis and vastus intermedia muscle forces were significantly (P < 0.05) greater with the 45 compared 30cm. The most significant (P < 0.05) increase was the vastus medialis which improved by around 50% with the 45 compared to 30cm (Table 2).

Table 1

Muscle force data (N /kg) during landing between the braced and non-braced at peak GRF
Muscle force at peak GRF	Height(cm)	Brace	No brace	F level B/N	F level height	F level interaction
Gluteus maximus	30	17.62 ± 7.04	19.60 ± 8.52	0.19	5.38*	0.00
Gluteus maximus	45	17.14 ± 9.43	19.06 ± 8.72	0.19	5.38*	0.00
Gluteus medius	30	16.78 ± 9.16	19.04 ± 10.66	0.00	0.01	2.18
Gluteus medius	45	19.12 ± 12.80	16.63 ± 9.41	0.00	0.01	2.18
Gluteus minimus	30	3.29 ± 3.41	3.70 ± 4.56	0.08	1.42	2.66
Gluteus minimus	45	4.61 ± 5.40	2.76 ± 2.79	0.08	1.42	2.66
Rectus femoris	30	1.65 ± 5.44	0.44 ± 0.98	3.83	1.38	0.22
Rectus femoris	45	2.51 ± 5.37	1.95 ± 4.12	3.83	1.38	0.22
Vastus medialis	30	8.87 ± 3.32	8.17 ± 3.26	112.22*	0.28	0.23
Vastus medialis	45	15.10 ± 5.03	15.02 ± 4.97	112.22*	0.28	0.23
Vastus intermedius	30	10.41 ± 3.75	9.65 ± 3.88	111.41*	0.24	0.22
Vastus intermedius	45	17.79 ± 5.84	17.71 ± 5.76	111.41*	0.24	0.22
Vastus lateralis	30	19.10 ± 6.36	18.08 ± 7.17	106.19*	0.25	0.09
Vastus lateralis	45	31.08 ± 9.35	30.72 ± 7.86	106.19*	0.25	0.09
Medial gastrocnemius	30	1.15 ± 1.90	1.16 ± 1.77	7.62*	0.82	0.79
Medial gastrocnemius	45	3.20 ± 5.47	4.48 ± 4.48	7.62*	0.82	0.79
Lateral gastrocnemius	30	2.27 ± 3.38	3.4 ± 4.53	13.41*	2.97	0.12
Lateral gastrocnemius	45	5.84 ± 5.71	6.83 ± 6.31	13.41*	2.97	0.12
Soleus	30	32.09 ± 19.72	25.81 ± 20.27	25.65*	0.95	3.17
Soleus	45	42.69 ± 19.30	44.01 ± 19.03	25.65*	0.95	3.17
* p < 0. 05

Table 2

Muscle force data (N /kg) during landing between the braced and non-braced at maximum knee flexion.
Muscle force at maximum knee flexion	Height (cm)	Brace	No brace	F level B/N	F level height	F level interaction
Gluteus maximus	30	11.76 ± 5.50	12.22 ± 4.79	2.09	0.40	0.02
Gluteus maximus	45	12.93 ± 6.05	13.49 ± 5.54	2.09	0.40	0.02
Gluteus medius	30	18.24 ± 7.80	20.59 ± 7.40	0.85	2.01	3.93
Gluteus medius	45	20.49 ± 8.59	20.18 ± 8.94	0.85	2.01	3.93
Gluteus minimus	30	4.48 ± 3.40	4.35 ± 2.93	4.66*	2.91	1.80
Gluteus minimus	45	6.02 ± 4.54	4.97 ± 3.85	4.66*	2.91	1.80
Rectus femoris	30	2.98 ± 4.63	2.59 ± 4.08	10.53*	1.23	0.20
Rectus femoris	45	6.18 ± 6.73	5.20 ± 7.80	10.53*	1.23	0.20
Vastus medialis	30	10.43 ± 5.44	9.24 ± 5.05	103.61*	4.97*	0.00
Vastus medialis	45	15.27 ± 3.77	14.08 ± 4.79	103.61*	4.97*	0.00
Vastus intermedius	30	11.87 ± 5.82	10.60 ± 5.54	83.76*	4.73*	0.01
Vastus intermedius	45	16.89 ± 3.67	15.68 ± 4.84	83.76*	4.73*	0.01
Vastus lateralis	30	19.56 ± 7.98	17.86 ± 8.20	44.74*	2.73	0.39
Vastus lateralis	45	25.65 ± 4.28	24.82 ± 6.37	44.74*	2.73	0.39
Medial gastrocnemius	30	7.54 ± 9.14	8.99 ± 9.36	23.78*	0.18	0.44
Medial gastrocnemius	45	16.07 ± 9.75	15.52 ± 9.47	23.78*	0.18	0.44
Lateral gastrocnemius	30	4.91 ± 4.41	4.35 ± 3.81	21.15*	2.50	0.04
Lateral gastrocnemius	45	7.50 ± 4.01	6.74 ± 3.87	21.15*	2.50	0.04
Soleus	30	45.27 ± 6.04	44.01 ± 11.17	0.95	0.47	0.08
Soleus	45	43.58 ± 9.90	43.10 ± 10.00	0.95	0.47	0.08
* p < 0. 05

This is the first study to examine the effect of a knee brace on lower limb muscle forces during single-leg landings at two different heights using OpenSim simulations. The purpose of this study was to evaluate whether wearing a knee brace had an effect on the muscular forces generated during single-leg landings at two different landing heights. Our research revealed that wearing a knee brace may help avoid ACL injuries by strengthening the lower limb muscle. It supported our first hypothesis and demonstrated the important role of the knee brace in single-leg landings.

Our findings are not directly comparable to earlier studies due to differences in methodology and maneuvers. For example, one study discovered a significant decrease in quadriceps activity during cutting by braced [28]. A significant increase in quadriceps force was found in the gait support phase [29]. However, these two experiments used surface EMG to assess muscle activities. In comparison, we simulated them using static optimization which is a more efficient strategy [30]. Our findings suggested that wearing a knee brace increased quadriceps force during single-leg landings at the maximal knee flexion angle (Table 2). Additionally, we observed a significant increase in VAS (rectus, vastus medialis, and vastus lateralis) muscle forces during braced single-leg landings (Table 1), which is similar to a simulation investigation of the effect of a knee brace on double-leg landings [31]. Quadriceps forces are critical for dynamic knee stability and avoiding ACL injuries [32, 33]. Our findings imply that wearing a knee brace may help avoid ACL injuries by increasing quadriceps muscle forces.

Additionally, knee braces had a significant influence on the muscles that do not cross the knee joint (gastrocnemius and soleus) during single-leg landings (Table 1). A study indicated that the amplitude of the medial gastrocnemius was significantly reduced according to surface EMG when braced [34]. We discovered that wearing the knee brace significantly reduced not only the medial gastrocnemius force but also the lateral gastrocnemius force during single-leg landings (Tables 1 and 2). This could be a result of the maneuvers being different. A study discovered that the soleus muscle force peak was much lower using Opensim with the braced [35] which was not exactly the same as our observations at peak GRF. Our findings indicated that the knee brace increased soleus muscle force at 30cm and decreased it at 45cm (Table 1). The gastrocnemius muscle's decreased activity as an ACL antagonist may be viewed as a protection mechanism against excessive anterior tibial translation [10, 36]. Our findings reveal that the knee brace may reduce gastrocnemius muscle force to prevent possible ACL injuries. The soleus muscle had been shown to play an agonistic role in ACL loading [37]. The knee brace had the opposite effect on the soleus at both heights (Table 1). This suggests that the knee brace may have different effects on the soleus muscle at different heights. Our findings indicate that the knee brace caused changes in muscle forces that do not cross the knee joint (gastrocnemius and soleus) during single-leg landings. As a result, we hypothesize that the knee brace may contribute to ACL injury prevention by regulating gastrocnemius and soleus forces.

The data also confirmed our second hypothesis. Landing from a larger height increased the forces of the gluteus maximus, vastus medius, and vastus medius muscle by about 50% (Tables 1 and 2). This was consistent with a significant increase in quadriceps forces from a double-leg landing at 60 cm compared to 30 cm [38]. High knee muscle forces are usually sustained by soft tissue structures, including ligaments and cartilage in the knee joint, especially at greater heights [39, 40]. As a result, the risk of knee injuries may increase as landing height increases, and landings from greater heights should be avoided.

Firstly, this study was conducted in a controlled laboratory environment and did not consider the effects of the external environment. Therefore, the landing tasks used in this study may not accurately represent landing maneuvers performed during training and competitions. Secondly, the human body is a complicated whole. While the single-leg landing had been standardized and practiced, the leg's stance and speed are not precisely regulated in the same way during the landings; Thirdly, a more diverse selection of knee braces would have offered a more accurate indicator of the issue.

Our study demonstrated that bracing had a significant effect on the gluteus minimus, rectus femoris, vastus medialis, vastus lateralis, gastrocnemius medialis, gastrocnemius lateralis, soleus, and tibialis anterior muscle. Thus, it may help prevent ACL injuries by regulating muscle forces with the braced during single-leg landings. The gluteus maximus, vastus medius, and vastus medius muscle forces were significantly increased with the braced during single-leg landings from 30cm to 45cm. This implied that single-leg landings from a greater height may increase the risk of knee joint injuries. Further research is required to determine the effects of various braces on specific maneuvers.

ACL：Anterior cruciate ligament; GRF：Ground reaction force；EMG：Electromyography；RMS：Root mean square；RRA：Residual reduction algorithm

Acknowledgments

We are very grateful to Dr. Fan Gao from the School of Engineering at the University of Kentucky. With his help, we have a deeper understanding of OpenSim.

Author contributions

WY ran the simulations, analyzed and interpreted the data, and drafted the manuscript. HY helped write the manuscript. WC, LH and YD helped edit the final manuscript. All authors read and approved the final manuscript.

Funding

The research described in this report was supported by the National Natural Science Foundation of China (Grant no. 81728009).

Availability of data and materials

The data used to support the findings of this study are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

The Biological and Medical Ethics Committee of the Dalian University of Technology approved this study. And each participant provided their informed consent. All methods were performed in accordance with the latest version of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

1Department of Kinesiology and Health Promotion, Dalian University of Technology, Dalian, China

Yubin Wang, Yao Hou, Chenxiao Wu, Haibin Liu, Dan Yu

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The effect of a knee brace on muscle forces during single-leg landings at two heights

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