Joint contact forces when minimizing the external knee adduction moment by gait modification: A computer simulation study

Background and purpose: Gait modification is often used to reduce the external knee adduction moment (KAM) in human walking, but the relationship between ICAM reduction and changes in medial knee joint contact force (JCF) is not well established. Our purpose was to examine the limiting case of RAM-based gait modification: reducing the RAM as much as possible, and the resulting effects on JCF. Methods: We used musculoskeletal modeling to perform three optimal control simulations: normal walking, a modified gait that reduced the RAM as much as theoretically possible (Min(KAM) simulation), and a second modified gait that minimized the RAM plus the metabolic cost of transport (Min(KAM+CoT) simulation). Results: The two modified gaits both reduced the peak RAM from normal walking (-82% for Min(ICAM) simulation, -74% for Min(KAM+CoT) simulation) by increasing trunk lean, toe-out, and step width, and reducing knee flexion. Even though the Min(KAM+CoT) simulation had the larger RAM, it had a greater reduction in peak medial JCF (-27%) than the Min(KAM) simulation (-15%) because it reduced the RAM using less knee muscle activity. These results were qualitatively robust to a sensitivity analysis of the knee joint model, but the magnitude of changes varied by an order of magnitude. Conclusions: The results suggest that (i) gait modification can benefit from considering whole-body motion rather than single adjustments, (ii) accurate interpretation of RAM effects on medial JCF requires consideration of muscle forces, and (iii) subject-specific knee models are needed to accurately determine the magnitude of RAM reduction effects on JCF. (C) 2015 Elsevier B.V. All rights reserved.