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Disease Of The Musculoskeletal System
Accepted Manuscript Title: Sagittal plane pelvis motion influences transverse plane motion of the femur: Kinematic coupling at the hip joint Author: Jennifer J. Bagwell Thiago Y. Fukuda Christopher M. Powers PII: DOI: Reference:
S0966-6362(15)00877-2 http://dx.doi.org/doi:10.1016/j.gaitpost.2015.09.010 GAIPOS 4567
To appear in:
Gait & Posture
Received date: Revised date: Accepted date:
10-5-2015 31-8-2015 14-9-2015
Please cite this article as: Bagwell JJ, Fukuda TY, Powers CM, Sagittal plane pelvis motion influences transverse plane motion of the femur: Kinematic coupling at the hip joint, Gait and Posture (2015), http://dx.doi.org/10.1016/j.gaitpost.2015.09.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Highlights: - We assessed the effect of sagittal pelvis tilt on femur rotation - There was a relationship between anterior pelvis tilt and internal femur rotation
ip t
- There was a relationship between posterior pelvis tilt and external femur rotation
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te
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M
an
us
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- Altered sagittal plane pelvis movement may influence transverse plane femur movement
Page 1 of 19
2
Sagittal plane pelvis motion influences transverse plane motion of the femur:
ip t
Kinematic coupling at the hip joint
Jennifer J. Bagwell, PT, DPT, PhD1,3
cr
Thiago Y. Fukuda, PT, PhD2
Jacquelin Perry Musculoskeletal Biomechanics Laboratory, Division of Biokinesiology &
an
1
us
Christopher M. Powers, PT, PhD, FACSM, FAPTA1
Physical Therapy, University of Southern California, Los Angeles, CA, 90089, USA Knee and Hip Rehabilitation, Trata Institute; Department of Physical Therapy, Santa Casa of
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2
Ac ce p
Corresponding Author:
te
d
São Paulo, São Paulo-SP, Brazil
Jennifer Bagwell
Department of Physical Therapy, Creighton University 2500 California Plaza, Omaha, NE 68178, USA Ph: 919-698-5439
Fax: 402-280-5692 Email: [email protected]
Page 2 of 19
3
INTRODUCTION The hip joint is a complex anatomical structure comprised of the pelvis and the femur. The inherent stability of the hip occurs secondary to the ball and socket bony morphology, the
ip t
thick capsule and ligaments [1, 2], and the strong muscles surrounding the joint [1]. As a result
likely that movement of one segment may influence the other.
cr
of the highly congruent nature of this joint and the closely approximated joint surfaces [1, 3] it is
us
Previous studies have suggested a potential relationship between transverse plane femur and sagittal plane pelvis motions [4-7]. Duval, et al. [4] reported that internal rotation of the
an
lower extremity during standing resulted in an anterior pelvis tilt and external rotation of the lower extremity resulted in a posterior pelvis tilt. These authors proposed that this kinematic
M
relationship occurred as a direct result of bony approximation between the femoral head and the
d
acetabulum [4]. Further support for kinematic coupling between the pelvis and the femur comes
te
from studies in which calcaneal wedging was used to induce foot pronation [5-7]. These studies revealed that calcaneal eversion resulted in internal tibia rotation, internal femur rotation, and
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anterior pelvis tilting [5-7]. The kinematic relationship between the pelvis and femur has been shown to exist during bilateral [5, 6] and unilateral standing [6, 7]. The fact that transverse plane motion of the femur can influence sagittal plane motion of the pelvis is suggestive of kinematic coupling between these two segments. Coupling arises when a force or torque in one direction causes motion in another direction [8]. At the foot-ankle complex, for example, there is a well-studied relationship between calcaneal eversion and internal tibia rotation [9, 10]. In the cervical spine, axial rotation has been shown to be coupled with ipsilateral lateral flexion [11, 12]. While previous research supports the premise that internal femur rotation contributes to anterior pelvis tilt [4-7], it is not clear if the same coupling
Page 3 of 19
4
relationship occurs reciprocally (i.e. whether sagittal plane pelvis motion influences transverse plane femur motion). Additionally, research in this area has focused on upright standing postures [4-7], so it is not known if the same coupling behavior exists at greater hip flexion angles similar
ip t
to those that occur during functional tasks.
The purpose of the current study was to systematically explore whether there is a
cr
consistent and predictable kinematic relationship between sagittal plane motion of the pelvis and
us
transverse plane motion of the femur during anterior and posterior pelvis tilting. It was hypothesized that sagittal plane pelvis motion and transverse plane femur motion would be
an
significantly correlated at various hip flexion angles. It also was hypothesized that the ratio between transverse femur motion and sagittal pelvis motion would be similar between anterior
M
and posterior pelvis tilting. The presence of kinematic coupling at the hip joint may have
d
implications for musculoskeletal conditions in which internal femur rotation has been shown to
Ac ce p
METHODS
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be contributory to pathology (i.e. femoroacetabular impingement).
Participants
Sixteen subjects consisting of 9 females (28.0 + 7.6 years; 60.8 + 7.5 kg; 164.6 + 5.2 cm) and 7 males; (29.3 + 4.8 years; 76.1 + 10.4 kg; 178.0 + 4.7 cm) participated in this study. Participants had no history of hip pain, no previous hip surgery, and no complaints of lower extremity or low back pain during the preceding 6 months. Data collection occurred in the Jacquelin Perry Musculoskeletal Biomechanics Research Laboratory at the University of Southern California. Prior to participation, all subjects were informed of the purpose of the study and provided written informed consent.
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Procedures Three-dimensional kinematics were collected at 250 Hz using an 11-camera Qualisys
ip t
motion analysis system (Qualisys AB, Göteborg, Sweden). Reflective markers (11 mm diameter) were placed on the most distal aspect of the second toes, the first and fifth metatarsal heads, the
cr
medial and lateral malleoli, the medial and lateral femoral epicondyles, the greater trochanters,
us
the iliac crests, and the L5-S1 junction. Semi-rigid plastic plates with mounted tracking markers were secured to the heels, shanks, and thighs (Figure 1). Prior to data collection, a standing
an
calibration trial was collected to determine the segmental coordinate systems and the joint
markers on the iliac crests, and the L5-S1.
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centers. All markers were then removed with the exception of the semi-rigid clusters and the
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Subjects were instructed to stand upright with the feet stationary, shoulder width apart,
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toes pointing forward with shoulders flexed to 90°. Participants then performed a maximum anterior and posterior pelvis tilt without moving at the trunk or flexing the knees. Subjects
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practiced this motion at a set pace of 20 beats-per-minute in each direction (maximum anterior pelvis tilt to maximum posterior pelvis tilt) until they were comfortable with the task. Approximately five to 15 practice trials were performed. Following familiarization with the movement, five continuous repetitions of this task were performed. Subjects then performed a bilateral squat to 30° of hip flexion as determined using a goniometer. Starting from this position, subjects again performed five repetitions of maximum anterior and posterior tilt of the pelvis at the same pace described above. This task subsequently was performed at hip flexion angles of 60° and 90° (Figure 2). All subjects were able to successfully perform the desired pelvis motions for all knee flexion conditions.
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Data Analysis Three-dimensional kinematic data were processed with Visual 3D software (C-motion, Inc., Germantown, MD). Kinematic data were low-pass filtered at 6 Hz using a 4th-order
ip t
Butterworth filter. The middle three repetitions at each hip flexion angle for each subject were averaged. The femur and pelvis angles were calculated as the orientation of the femur and pelvis
cr
segments relative to the global coordinate system. The average of the three repetitions for
us
each hip flexion angle was calculated from the individual participant's data. The individual means for the 16 participants were then averaged at each hip flexion angle to create the
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average angle-angle plot.
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Statistical Analysis
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The ratio of femur transverse motion to pelvis sagittal motion was calculated at each hip
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flexion angle as the unstandardized coefficient of the linear regression of the average data during the period of anterior pelvis tilt and during the period of posterior pelvis tilt using PASW
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software (SPSS, Inc., Chicago, IL). This provided an estimate of the change in femur transverse rotation per degree of pelvis sagittal tilt. The R2 value for the mean femur transverse angles and the mean pelvis sagittal angles throughout this motion also was calculated for each hip flexion angle.
RESULTS All kinematic variables of interest demonstrated acceptable normality with skewedness and kurtosis values less than +/-0.5 and +/-2, respectively. Mean transverse plane femur excursions during the 0°, 30°, 60°, and 90° hip flexion angle conditions were 7.4 + 4.3°,
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7.0 + 5.5°, 5.6 + 4.2°, and 5.3 + 2.8°, respectively. Mean sagittal plane pelvis excursions during the 0°, 30°, 60°, and 90° hip flexion angle conditions were 23.4 + 7.5°, 20.8 + 12.2°, 20.3 + 11.9°, and 16.6 + 8.9°, respectively. The average femur transverse motion to pelvis sagittal
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motion ratios ranged from 0.23 to 0.32 and from 0.25 to 0.31 for anterior and posterior tilting, respectively (Table 1 and Figures 3 and 4). The R2 values between femur transverse and pelvis
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sagittal motion indicated a strong, linear relationship at each hip flexion angle tested (R2 values
us
of 0.97 or greater; Figures 3 and 4).
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DISCUSSION
A consistent pattern of kinematic coupling of anterior pelvis tilt and internal femur
M
rotation (and, conversely, posterior pelvis tilt and external femur rotation) was observed at each
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hip flexion angle evaluated. All 16 participants demonstrated this coupling behavior at the 0
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degree hip flexion condition, and 15 out of the 16 participants demonstrated the coupling behavior in the 30 degree, 60 degree, and 90 degree hip flexion conditions. When averaged
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across all hip flexion angles, there was 1.2-1.6° of internal femur rotation for every 5° of anterior pelvis tilt. Similarly, there was 1.2-1.6° of external femur rotation for every 5° of posterior pelvis tilt. This relationship was consistent across hip flexion angles and during periods of both anterior and posterior tilt, suggesting that kinematic coupling between these segments is robust.
Our findings confirm and expand upon previous reports of kinematic coupling between the femur and the pelvis [4-7]. Consistent with the current study, Duval et al (2010) found a significant relationship between internal femur rotation and anterior pelvis tilt. Contrary to the findings of the current study, however, these authors reported that the relationship between
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8
external femur rotation and posterior pelvis tilt was less pronounced than that between internal femur rotation and anterior pelvis tilt [4]. The findings of the current study reveal that coupling was nearly identical during anterior pelvis tilting and posterior pelvis tilting.
ip t
To the best of our knowledge, this is the first study to demonstrate that motion of the pelvis in the sagittal plane can influence motion of the femur in the transverse plane. While it is
cr
beyond the scope of this paper to explain the mechanism underlying the observed coupling,
us
several possibilities exist. Motion at any joint is heavily influenced by bony anatomy. The hip joint, in particular, is highly congruent with closely approximated joint surfaces [1, 3] secondary
an
to its thick capsule [1, 2], strong musculature [1], and the negative pressure within the joint space [13]. As such, it is logical that motion of one segment would have a predictable influence on the
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other. Many highly congruent joints exhibit kinematic coupling. For example, the relationship at
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documented [9, 10].
d
the foot-ankle complex between calcaneal eversion and tibial internal rotation has been well
Duval, et al. (2010) suggested that internal rotation of the femur causes the femoral head
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to rotate posteriorly into the posterior acetabulum which pushes the pelvis into an anterior tilt. Conversely, it is possible that anterior tilt of the pelvis rotates the acetabulum antero-inferiorly into the anterior femoral head, which pushes the femur into internal rotation. Other factors, such as muscle activation, soft tissue length, and bony alignment (i.e. femoral or acetabular version or inclination) also may influence intersegmental coupling [4]. Understanding contributory factors to hip joint motion is important in populations where abnormal kinematics have been implicated. In persons with femoroacetabular impingement, for example, anterior pelvis tilt and femur internal rotation increase approximation of the femoral head-neck junction with the acetabulum [14, 15]. Such abutment is hypothesized to contribute to
Page 8 of 19
9
labral damage [16-18], chondral damage [16, 17, 19], and hip osteoarthritis [20, 21]. Additionally, kinematic studies have identified differences in sagittal [22-25] and transverse plane hip and pelvis kinematics [23, 25] between persons with and without femoroacetabular
ip t
impingement. Our findings indicate that altered sagittal plane pelvis kinematics in persons with femoroacetabular impingement may influence hip rotation.
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There are certain limitations of this study that should be considered when interpreting the
us
results. Skin markers were used to assess segment position and may have been subject to soft tissue movement artifact. Marker artifact error was minimized however through use of
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thigh clusters comprised of four markers [26], and the fact that we studied of a relatively slow movement with minimal inertial effects [27]. Another limitation is that only isolated
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intentional motion of the pelvis was examined. The ratio of femur to pelvis motion may vary
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during more dynamic tasks that involve greater excursions and muscular demands. The ratio
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between femur rotation and pelvis tilt also may differ between weightbearing and nonweightbearing tasks. Furthermore, the coupling behavior only was evaluated in healthy
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participants. The reported coupling ratios may differ in persons with hip or back pain. The ratios also may differ in the presence of abnormal bony morphology of the hip.
CONCLUSIONS
To the best of our knowledge, this study is the first to systematically explore the coupling behavior between the pelvis and femur during a dynamic task, across varying degrees of hip flexion. A consistent pattern of kinematic coupling of anterior pelvis tilt and internal femur rotation and, conversely, posterior pelvis tilt and external femur rotation, was observed at hip flexion angles ranging from 0°-90°. For every 5° of anterior pelvis tilt there was
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1.2-1.6° of internal femur rotation and for every 5° of posterior pelvis tilt there was a similar 1.21.6° of external femur rotation. Our findings suggest that altered pelvis control or positioning in the sagittal plane has the potential to influence transverse plane motion of the femur. Our
ip t
findings may have clinical applications, particularly for populations that exhibit altered
Ac ce p
te
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pelvis or femur kinematics.
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REFERENCES
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[1] Safran MR, Lopomo N, Zaffagnini S, Signorelli C, Vaughn ZD, Lindsey DP, et al. In vitro analysis of peri-articular soft tissues passive constraining effect on hip kinematics and joint stability. Knee Surg Sports Traumatol Arthrosc 2013;21:1655-63. [2] Philippon MJ, Michalski MP, Campbell KJ, Rasmussen MT, Goldsmith MT, Devitt BM, et al. A quantitative analysis of hip capsular thickness. Knee Surg Sports Traumatol Arthrosc 2014. [3] Llopis E, Cerezal L, Kassarjian A, Higueras V, Fernandez E. Direct MR arthrography of the hip with leg traction: feasibility for assessing articular cartilage. AJR Am J Roentgenol 2008;190:1124-8. [4] Duval K, Lam T, Sanderson D. The mechanical relationship between the rearfoot, pelvis and low-back. Gait Posture 2010;32:637-40. [5] Khamis S, Yizhar Z. Effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture 2007;25:127-34. [6] Pinto RZ, Souza TR, Trede RG, Kirkwood RN, Figueiredo EM, Fonseca ST. Bilateral and unilateral increases in calcaneal eversion affect pelvic alignment in standing position. Man Ther 2008;13:513-9. [7] Tateuchi H, Wada O, Ichihashi N. Effects of calcaneal eversion on three-dimensional kinematics of the hip, pelvis and thorax in unilateral weight bearing. Human movement science 2011;30:566-73. [8] Raynor RB, Moskovich R, Zidel P, Pugh J. Alterations in primary and coupled neck motions after facetectomy. Neurosurgery 1987;21:681-7. [9] Hintermann B, Nigg BM, Sommer C, Cole GK. Transfer of movement between calcaneus and tibia in vitro. Clinical biomechanics 1994;9:349-55. [10] Tillman MD, Hass CJ, Chow JW, Brunt D. Lower extremity coupling parameters during locomotion and landings. Journal of applied biomechanics 2005;21:359-70. [11] Wachowski MM, Mansour M, Lee C, Ackenhausen A, Spiering S, Fanghanel J, et al. How do spinal segments move? Journal of biomechanics 2009;42:2286-93. [12] Cook C, Hegedus E, Showalter C, Sizer PS, Jr. Coupling behavior of the cervical spine: a systematic review of the literature. Journal of manipulative and physiological therapeutics 2006;29:570-5. [13] Nepple JJ, Philippon MJ, Campbell KJ, Dornan GJ, Jansson KS, LaPrade RF, et al. The hip fluid seal--Part II: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction. Knee Surg Sports Traumatol Arthrosc 2014;22:730-6. [14] Jorge JP, Simoes FM, Pires EB, Rego PA, Tavares DG, Lopes DS, et al. Finite element simulations of a hip joint with femoroacetabular impingement. Computer methods in biomechanics and biomedical engineering 2014;17:1275-84. [15] Arbabi E, Chegini S, Boulic R, Tannast M, Ferguson SJ, Thalmann D. Penetration depth method--novel real-time strategy for evaluating femoroacetabular impingement. J Orthop Res 2010;28:880-6. [16] Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-articular hip disease in arthroscopy. Am J Sports Med 2011;39:296-303.
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[17] Johnston TL, Schenker ML, Briggs KK, Philippon MJ. Relationship between offset angle alpha and hip chondral injury in femoroacetabular impingement. Arthroscopy 2008;24:669-75. [18] Tamura S, Nishii T, Takao M, Sakai T, Yoshikawa H, Sugano N. Differences in the locations and modes of labral tearing between dysplastic hips and those with femoroacetabular impingement. The bone & joint journal 2013;95-B:1320-5. [19] Kaya M, Suzuki T, Emori M, Yamashita T. Hip morphology influences the pattern of articular cartilage damage. Knee Surg Sports Traumatol Arthrosc 2014. [20] Agricola R, Heijboer MP, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Waarsing JH. Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK). Annals of the rheumatic diseases 2013;72:918-23. [21] Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a populationbased survey. J Bone Joint Surg Am 2010;92:1162-9. [22] Lamontagne M, Kennedy MJ, Beaule PE. The effect of cam FAI on hip and pelvic motion during maximum squat. Clin Orthop Relat Res 2009;467:645-50. [23] Rylander J, Shu B, Favre J, Safran M, Andriacchi T. Functional testing provides unique insights into the pathomechanics of femoroacetabular impingement and an objective basis for evaluating treatment outcome. J Orthop Res 2013;31:1461-8. [24] Ng KC, Lamontagne M, Adamczyk AP, Rahkra KS, Beaule PE. Patient-Specific Anatomical and Functional Parameters Provide New Insights into the Pathomechanism of Cam FAI. Clin Orthop Relat Res 2014. [25] Hunt MA, Guenther JR, Gilbart MK. Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement. Clinical biomechanics 2013;28:519-23. [26] Cappozzo A, Cappello A, Della Croce U, Pensalfini F. Surface-marker cluster design criteria for 3-D bone movement reconstruction. IEEE transactions on bio-medical engineering 1997;44:1165-74. [27] Hatze H. The fundamental problem of myoskeletal inverse dynamics and its implications. Journal of biomechanics 2002;35:109-15.
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Table 1. Coupling ratios during maximum pelvis sagittal plane excursion for periods of anterior and posterior pelvis tilt 60° Hip Flexion 0.23 : 1 0.25 : 1
90° Hip Flexion 0.26 : 1 0.29 : 1
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Internal Femur Rotation: Anterior Pelvis Tilt External Femur Rotation: Posterior Pelvis Tilt
30° Hip Flexion 0.30 : 1 0.31 : 1
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0° Hip Flexion 0.32 : 1 0.31 : 1
Page 13 of 19
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Figure 1. Marker set utilized for static trial
Figure 2. Subject performing maximum posterior pelvis tilt (left) to maximum anterior pelvis tilt
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(right) at 60° of hip flexion. This task was repeated at hip flexion angles of 0°, 30°, and 90°.
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Figure 3. Average angle-angle diagram of the femur transverse plane kinematics versus the
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pelvis sagittal plane kinematics at hip flexion angles of 0°, 30°, 60°, and 90° while performing a
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maximum anterior pelvis tilt from a maximum posterior pelvis tilt. Star indicates starting point.
Figure 4. Average angle-angle diagram of the femur transverse plane kinematics versus the
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pelvis sagittal plane kinematics at hip flexion angles of 0°, 30°, 60°, and 90° while performing a
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maximum posterior pelvis tilt from a maximum anterior pelvis tilt. Star indicates starting point.
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Conflict of Interest Statement:
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There are no conflicts of interest to disclose
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7. Figure(s)
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Figure 1.
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7. Figure(s)
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Figure 2.
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Pelvis Posterior Tilt
0
-15
-5
-2
5
-4
-8 -10
25
35
0° Hip Flexion R2=0.97
30° Hip Flexion R2=0.98 60° Hip Flexion R2=0.98 90° Hip Flexion R2=0.99
ce pt
-12
15
Pelvis Anterior Tilt
ed
-6
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Femur Internal Rotation
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7. Figure(s)
Figure 3.
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Femur External Rotation
Page 18 of 19
Femur Internal Rotation
0
-15
-5
-2
5
-4 -6
-10
25
Pelvis Anterior Tilt
0° Hip Flexion
R2=0.99
35
30° Hip Flexion R2>0.99
60° Hip Flexion R2>0.99 90° Hip Flexion R2>0.99
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-12
15
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-8
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2
Pelvis Posterior Tilt
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7. Figure(s)
Figure 4.
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Femur External Rotation
Page 19 of 19
S0966-6362(15)00877-2 http://dx.doi.org/doi:10.1016/j.gaitpost.2015.09.010 GAIPOS 4567
To appear in:
Gait & Posture
Received date: Revised date: Accepted date:
10-5-2015 31-8-2015 14-9-2015
Please cite this article as: Bagwell JJ, Fukuda TY, Powers CM, Sagittal plane pelvis motion influences transverse plane motion of the femur: Kinematic coupling at the hip joint, Gait and Posture (2015), http://dx.doi.org/10.1016/j.gaitpost.2015.09.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Highlights: - We assessed the effect of sagittal pelvis tilt on femur rotation - There was a relationship between anterior pelvis tilt and internal femur rotation
ip t
- There was a relationship between posterior pelvis tilt and external femur rotation
Ac ce p
te
d
M
an
us
cr
- Altered sagittal plane pelvis movement may influence transverse plane femur movement
Page 1 of 19
2
Sagittal plane pelvis motion influences transverse plane motion of the femur:
ip t
Kinematic coupling at the hip joint
Jennifer J. Bagwell, PT, DPT, PhD1,3
cr
Thiago Y. Fukuda, PT, PhD2
Jacquelin Perry Musculoskeletal Biomechanics Laboratory, Division of Biokinesiology &
an
1
us
Christopher M. Powers, PT, PhD, FACSM, FAPTA1
Physical Therapy, University of Southern California, Los Angeles, CA, 90089, USA Knee and Hip Rehabilitation, Trata Institute; Department of Physical Therapy, Santa Casa of
M
2
Ac ce p
Corresponding Author:
te
d
São Paulo, São Paulo-SP, Brazil
Jennifer Bagwell
Department of Physical Therapy, Creighton University 2500 California Plaza, Omaha, NE 68178, USA Ph: 919-698-5439
Fax: 402-280-5692 Email: [email protected]
Page 2 of 19
3
INTRODUCTION The hip joint is a complex anatomical structure comprised of the pelvis and the femur. The inherent stability of the hip occurs secondary to the ball and socket bony morphology, the
ip t
thick capsule and ligaments [1, 2], and the strong muscles surrounding the joint [1]. As a result
likely that movement of one segment may influence the other.
cr
of the highly congruent nature of this joint and the closely approximated joint surfaces [1, 3] it is
us
Previous studies have suggested a potential relationship between transverse plane femur and sagittal plane pelvis motions [4-7]. Duval, et al. [4] reported that internal rotation of the
an
lower extremity during standing resulted in an anterior pelvis tilt and external rotation of the lower extremity resulted in a posterior pelvis tilt. These authors proposed that this kinematic
M
relationship occurred as a direct result of bony approximation between the femoral head and the
d
acetabulum [4]. Further support for kinematic coupling between the pelvis and the femur comes
te
from studies in which calcaneal wedging was used to induce foot pronation [5-7]. These studies revealed that calcaneal eversion resulted in internal tibia rotation, internal femur rotation, and
Ac ce p
anterior pelvis tilting [5-7]. The kinematic relationship between the pelvis and femur has been shown to exist during bilateral [5, 6] and unilateral standing [6, 7]. The fact that transverse plane motion of the femur can influence sagittal plane motion of the pelvis is suggestive of kinematic coupling between these two segments. Coupling arises when a force or torque in one direction causes motion in another direction [8]. At the foot-ankle complex, for example, there is a well-studied relationship between calcaneal eversion and internal tibia rotation [9, 10]. In the cervical spine, axial rotation has been shown to be coupled with ipsilateral lateral flexion [11, 12]. While previous research supports the premise that internal femur rotation contributes to anterior pelvis tilt [4-7], it is not clear if the same coupling
Page 3 of 19
4
relationship occurs reciprocally (i.e. whether sagittal plane pelvis motion influences transverse plane femur motion). Additionally, research in this area has focused on upright standing postures [4-7], so it is not known if the same coupling behavior exists at greater hip flexion angles similar
ip t
to those that occur during functional tasks.
The purpose of the current study was to systematically explore whether there is a
cr
consistent and predictable kinematic relationship between sagittal plane motion of the pelvis and
us
transverse plane motion of the femur during anterior and posterior pelvis tilting. It was hypothesized that sagittal plane pelvis motion and transverse plane femur motion would be
an
significantly correlated at various hip flexion angles. It also was hypothesized that the ratio between transverse femur motion and sagittal pelvis motion would be similar between anterior
M
and posterior pelvis tilting. The presence of kinematic coupling at the hip joint may have
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implications for musculoskeletal conditions in which internal femur rotation has been shown to
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METHODS
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be contributory to pathology (i.e. femoroacetabular impingement).
Participants
Sixteen subjects consisting of 9 females (28.0 + 7.6 years; 60.8 + 7.5 kg; 164.6 + 5.2 cm) and 7 males; (29.3 + 4.8 years; 76.1 + 10.4 kg; 178.0 + 4.7 cm) participated in this study. Participants had no history of hip pain, no previous hip surgery, and no complaints of lower extremity or low back pain during the preceding 6 months. Data collection occurred in the Jacquelin Perry Musculoskeletal Biomechanics Research Laboratory at the University of Southern California. Prior to participation, all subjects were informed of the purpose of the study and provided written informed consent.
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Procedures Three-dimensional kinematics were collected at 250 Hz using an 11-camera Qualisys
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motion analysis system (Qualisys AB, Göteborg, Sweden). Reflective markers (11 mm diameter) were placed on the most distal aspect of the second toes, the first and fifth metatarsal heads, the
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medial and lateral malleoli, the medial and lateral femoral epicondyles, the greater trochanters,
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the iliac crests, and the L5-S1 junction. Semi-rigid plastic plates with mounted tracking markers were secured to the heels, shanks, and thighs (Figure 1). Prior to data collection, a standing
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calibration trial was collected to determine the segmental coordinate systems and the joint
markers on the iliac crests, and the L5-S1.
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centers. All markers were then removed with the exception of the semi-rigid clusters and the
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Subjects were instructed to stand upright with the feet stationary, shoulder width apart,
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toes pointing forward with shoulders flexed to 90°. Participants then performed a maximum anterior and posterior pelvis tilt without moving at the trunk or flexing the knees. Subjects
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practiced this motion at a set pace of 20 beats-per-minute in each direction (maximum anterior pelvis tilt to maximum posterior pelvis tilt) until they were comfortable with the task. Approximately five to 15 practice trials were performed. Following familiarization with the movement, five continuous repetitions of this task were performed. Subjects then performed a bilateral squat to 30° of hip flexion as determined using a goniometer. Starting from this position, subjects again performed five repetitions of maximum anterior and posterior tilt of the pelvis at the same pace described above. This task subsequently was performed at hip flexion angles of 60° and 90° (Figure 2). All subjects were able to successfully perform the desired pelvis motions for all knee flexion conditions.
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Data Analysis Three-dimensional kinematic data were processed with Visual 3D software (C-motion, Inc., Germantown, MD). Kinematic data were low-pass filtered at 6 Hz using a 4th-order
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Butterworth filter. The middle three repetitions at each hip flexion angle for each subject were averaged. The femur and pelvis angles were calculated as the orientation of the femur and pelvis
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segments relative to the global coordinate system. The average of the three repetitions for
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each hip flexion angle was calculated from the individual participant's data. The individual means for the 16 participants were then averaged at each hip flexion angle to create the
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average angle-angle plot.
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Statistical Analysis
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The ratio of femur transverse motion to pelvis sagittal motion was calculated at each hip
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flexion angle as the unstandardized coefficient of the linear regression of the average data during the period of anterior pelvis tilt and during the period of posterior pelvis tilt using PASW
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software (SPSS, Inc., Chicago, IL). This provided an estimate of the change in femur transverse rotation per degree of pelvis sagittal tilt. The R2 value for the mean femur transverse angles and the mean pelvis sagittal angles throughout this motion also was calculated for each hip flexion angle.
RESULTS All kinematic variables of interest demonstrated acceptable normality with skewedness and kurtosis values less than +/-0.5 and +/-2, respectively. Mean transverse plane femur excursions during the 0°, 30°, 60°, and 90° hip flexion angle conditions were 7.4 + 4.3°,
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7.0 + 5.5°, 5.6 + 4.2°, and 5.3 + 2.8°, respectively. Mean sagittal plane pelvis excursions during the 0°, 30°, 60°, and 90° hip flexion angle conditions were 23.4 + 7.5°, 20.8 + 12.2°, 20.3 + 11.9°, and 16.6 + 8.9°, respectively. The average femur transverse motion to pelvis sagittal
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motion ratios ranged from 0.23 to 0.32 and from 0.25 to 0.31 for anterior and posterior tilting, respectively (Table 1 and Figures 3 and 4). The R2 values between femur transverse and pelvis
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sagittal motion indicated a strong, linear relationship at each hip flexion angle tested (R2 values
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of 0.97 or greater; Figures 3 and 4).
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DISCUSSION
A consistent pattern of kinematic coupling of anterior pelvis tilt and internal femur
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rotation (and, conversely, posterior pelvis tilt and external femur rotation) was observed at each
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hip flexion angle evaluated. All 16 participants demonstrated this coupling behavior at the 0
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degree hip flexion condition, and 15 out of the 16 participants demonstrated the coupling behavior in the 30 degree, 60 degree, and 90 degree hip flexion conditions. When averaged
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across all hip flexion angles, there was 1.2-1.6° of internal femur rotation for every 5° of anterior pelvis tilt. Similarly, there was 1.2-1.6° of external femur rotation for every 5° of posterior pelvis tilt. This relationship was consistent across hip flexion angles and during periods of both anterior and posterior tilt, suggesting that kinematic coupling between these segments is robust.
Our findings confirm and expand upon previous reports of kinematic coupling between the femur and the pelvis [4-7]. Consistent with the current study, Duval et al (2010) found a significant relationship between internal femur rotation and anterior pelvis tilt. Contrary to the findings of the current study, however, these authors reported that the relationship between
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external femur rotation and posterior pelvis tilt was less pronounced than that between internal femur rotation and anterior pelvis tilt [4]. The findings of the current study reveal that coupling was nearly identical during anterior pelvis tilting and posterior pelvis tilting.
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To the best of our knowledge, this is the first study to demonstrate that motion of the pelvis in the sagittal plane can influence motion of the femur in the transverse plane. While it is
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beyond the scope of this paper to explain the mechanism underlying the observed coupling,
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several possibilities exist. Motion at any joint is heavily influenced by bony anatomy. The hip joint, in particular, is highly congruent with closely approximated joint surfaces [1, 3] secondary
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to its thick capsule [1, 2], strong musculature [1], and the negative pressure within the joint space [13]. As such, it is logical that motion of one segment would have a predictable influence on the
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other. Many highly congruent joints exhibit kinematic coupling. For example, the relationship at
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documented [9, 10].
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the foot-ankle complex between calcaneal eversion and tibial internal rotation has been well
Duval, et al. (2010) suggested that internal rotation of the femur causes the femoral head
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to rotate posteriorly into the posterior acetabulum which pushes the pelvis into an anterior tilt. Conversely, it is possible that anterior tilt of the pelvis rotates the acetabulum antero-inferiorly into the anterior femoral head, which pushes the femur into internal rotation. Other factors, such as muscle activation, soft tissue length, and bony alignment (i.e. femoral or acetabular version or inclination) also may influence intersegmental coupling [4]. Understanding contributory factors to hip joint motion is important in populations where abnormal kinematics have been implicated. In persons with femoroacetabular impingement, for example, anterior pelvis tilt and femur internal rotation increase approximation of the femoral head-neck junction with the acetabulum [14, 15]. Such abutment is hypothesized to contribute to
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labral damage [16-18], chondral damage [16, 17, 19], and hip osteoarthritis [20, 21]. Additionally, kinematic studies have identified differences in sagittal [22-25] and transverse plane hip and pelvis kinematics [23, 25] between persons with and without femoroacetabular
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impingement. Our findings indicate that altered sagittal plane pelvis kinematics in persons with femoroacetabular impingement may influence hip rotation.
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There are certain limitations of this study that should be considered when interpreting the
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results. Skin markers were used to assess segment position and may have been subject to soft tissue movement artifact. Marker artifact error was minimized however through use of
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thigh clusters comprised of four markers [26], and the fact that we studied of a relatively slow movement with minimal inertial effects [27]. Another limitation is that only isolated
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intentional motion of the pelvis was examined. The ratio of femur to pelvis motion may vary
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during more dynamic tasks that involve greater excursions and muscular demands. The ratio
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between femur rotation and pelvis tilt also may differ between weightbearing and nonweightbearing tasks. Furthermore, the coupling behavior only was evaluated in healthy
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participants. The reported coupling ratios may differ in persons with hip or back pain. The ratios also may differ in the presence of abnormal bony morphology of the hip.
CONCLUSIONS
To the best of our knowledge, this study is the first to systematically explore the coupling behavior between the pelvis and femur during a dynamic task, across varying degrees of hip flexion. A consistent pattern of kinematic coupling of anterior pelvis tilt and internal femur rotation and, conversely, posterior pelvis tilt and external femur rotation, was observed at hip flexion angles ranging from 0°-90°. For every 5° of anterior pelvis tilt there was
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1.2-1.6° of internal femur rotation and for every 5° of posterior pelvis tilt there was a similar 1.21.6° of external femur rotation. Our findings suggest that altered pelvis control or positioning in the sagittal plane has the potential to influence transverse plane motion of the femur. Our
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findings may have clinical applications, particularly for populations that exhibit altered
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pelvis or femur kinematics.
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REFERENCES
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[1] Safran MR, Lopomo N, Zaffagnini S, Signorelli C, Vaughn ZD, Lindsey DP, et al. In vitro analysis of peri-articular soft tissues passive constraining effect on hip kinematics and joint stability. Knee Surg Sports Traumatol Arthrosc 2013;21:1655-63. [2] Philippon MJ, Michalski MP, Campbell KJ, Rasmussen MT, Goldsmith MT, Devitt BM, et al. A quantitative analysis of hip capsular thickness. Knee Surg Sports Traumatol Arthrosc 2014. [3] Llopis E, Cerezal L, Kassarjian A, Higueras V, Fernandez E. Direct MR arthrography of the hip with leg traction: feasibility for assessing articular cartilage. AJR Am J Roentgenol 2008;190:1124-8. [4] Duval K, Lam T, Sanderson D. The mechanical relationship between the rearfoot, pelvis and low-back. Gait Posture 2010;32:637-40. [5] Khamis S, Yizhar Z. Effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture 2007;25:127-34. [6] Pinto RZ, Souza TR, Trede RG, Kirkwood RN, Figueiredo EM, Fonseca ST. Bilateral and unilateral increases in calcaneal eversion affect pelvic alignment in standing position. Man Ther 2008;13:513-9. [7] Tateuchi H, Wada O, Ichihashi N. Effects of calcaneal eversion on three-dimensional kinematics of the hip, pelvis and thorax in unilateral weight bearing. Human movement science 2011;30:566-73. [8] Raynor RB, Moskovich R, Zidel P, Pugh J. Alterations in primary and coupled neck motions after facetectomy. Neurosurgery 1987;21:681-7. [9] Hintermann B, Nigg BM, Sommer C, Cole GK. Transfer of movement between calcaneus and tibia in vitro. Clinical biomechanics 1994;9:349-55. [10] Tillman MD, Hass CJ, Chow JW, Brunt D. Lower extremity coupling parameters during locomotion and landings. Journal of applied biomechanics 2005;21:359-70. [11] Wachowski MM, Mansour M, Lee C, Ackenhausen A, Spiering S, Fanghanel J, et al. How do spinal segments move? Journal of biomechanics 2009;42:2286-93. [12] Cook C, Hegedus E, Showalter C, Sizer PS, Jr. Coupling behavior of the cervical spine: a systematic review of the literature. Journal of manipulative and physiological therapeutics 2006;29:570-5. [13] Nepple JJ, Philippon MJ, Campbell KJ, Dornan GJ, Jansson KS, LaPrade RF, et al. The hip fluid seal--Part II: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction. Knee Surg Sports Traumatol Arthrosc 2014;22:730-6. [14] Jorge JP, Simoes FM, Pires EB, Rego PA, Tavares DG, Lopes DS, et al. Finite element simulations of a hip joint with femoroacetabular impingement. Computer methods in biomechanics and biomedical engineering 2014;17:1275-84. [15] Arbabi E, Chegini S, Boulic R, Tannast M, Ferguson SJ, Thalmann D. Penetration depth method--novel real-time strategy for evaluating femoroacetabular impingement. J Orthop Res 2010;28:880-6. [16] Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-articular hip disease in arthroscopy. Am J Sports Med 2011;39:296-303.
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[17] Johnston TL, Schenker ML, Briggs KK, Philippon MJ. Relationship between offset angle alpha and hip chondral injury in femoroacetabular impingement. Arthroscopy 2008;24:669-75. [18] Tamura S, Nishii T, Takao M, Sakai T, Yoshikawa H, Sugano N. Differences in the locations and modes of labral tearing between dysplastic hips and those with femoroacetabular impingement. The bone & joint journal 2013;95-B:1320-5. [19] Kaya M, Suzuki T, Emori M, Yamashita T. Hip morphology influences the pattern of articular cartilage damage. Knee Surg Sports Traumatol Arthrosc 2014. [20] Agricola R, Heijboer MP, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Waarsing JH. Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK). Annals of the rheumatic diseases 2013;72:918-23. [21] Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a populationbased survey. J Bone Joint Surg Am 2010;92:1162-9. [22] Lamontagne M, Kennedy MJ, Beaule PE. The effect of cam FAI on hip and pelvic motion during maximum squat. Clin Orthop Relat Res 2009;467:645-50. [23] Rylander J, Shu B, Favre J, Safran M, Andriacchi T. Functional testing provides unique insights into the pathomechanics of femoroacetabular impingement and an objective basis for evaluating treatment outcome. J Orthop Res 2013;31:1461-8. [24] Ng KC, Lamontagne M, Adamczyk AP, Rahkra KS, Beaule PE. Patient-Specific Anatomical and Functional Parameters Provide New Insights into the Pathomechanism of Cam FAI. Clin Orthop Relat Res 2014. [25] Hunt MA, Guenther JR, Gilbart MK. Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement. Clinical biomechanics 2013;28:519-23. [26] Cappozzo A, Cappello A, Della Croce U, Pensalfini F. Surface-marker cluster design criteria for 3-D bone movement reconstruction. IEEE transactions on bio-medical engineering 1997;44:1165-74. [27] Hatze H. The fundamental problem of myoskeletal inverse dynamics and its implications. Journal of biomechanics 2002;35:109-15.
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Table 1. Coupling ratios during maximum pelvis sagittal plane excursion for periods of anterior and posterior pelvis tilt 60° Hip Flexion 0.23 : 1 0.25 : 1
90° Hip Flexion 0.26 : 1 0.29 : 1
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Internal Femur Rotation: Anterior Pelvis Tilt External Femur Rotation: Posterior Pelvis Tilt
30° Hip Flexion 0.30 : 1 0.31 : 1
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0° Hip Flexion 0.32 : 1 0.31 : 1
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Figure 1. Marker set utilized for static trial
Figure 2. Subject performing maximum posterior pelvis tilt (left) to maximum anterior pelvis tilt
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(right) at 60° of hip flexion. This task was repeated at hip flexion angles of 0°, 30°, and 90°.
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Figure 3. Average angle-angle diagram of the femur transverse plane kinematics versus the
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pelvis sagittal plane kinematics at hip flexion angles of 0°, 30°, 60°, and 90° while performing a
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maximum anterior pelvis tilt from a maximum posterior pelvis tilt. Star indicates starting point.
Figure 4. Average angle-angle diagram of the femur transverse plane kinematics versus the
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pelvis sagittal plane kinematics at hip flexion angles of 0°, 30°, 60°, and 90° while performing a
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maximum posterior pelvis tilt from a maximum anterior pelvis tilt. Star indicates starting point.
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Conflict of Interest Statement:
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There are no conflicts of interest to disclose
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7. Figure(s)
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Figure 1.
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7. Figure(s)
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Figure 2.
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Pelvis Posterior Tilt
0
-15
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-2
5
-4
-8 -10
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0° Hip Flexion R2=0.97
30° Hip Flexion R2=0.98 60° Hip Flexion R2=0.98 90° Hip Flexion R2=0.99
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Pelvis Anterior Tilt
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Femur Internal Rotation
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7. Figure(s)
Figure 3.
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Femur External Rotation
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Femur Internal Rotation
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-4 -6
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Pelvis Anterior Tilt
0° Hip Flexion
R2=0.99
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30° Hip Flexion R2>0.99
60° Hip Flexion R2>0.99 90° Hip Flexion R2>0.99
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Pelvis Posterior Tilt
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7. Figure(s)
Figure 4.
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Femur External Rotation
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