Effects of Restricted Knee Flexion and Walking

Speed on the Vertical Ground Reaction Force

During Gait

Journal of Orthopaedic & Sports Physical Therapy

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Thomas M. Cook, PhD, PT'

Kevin P. Farrell, MA, PT, 0CS2
Iva A. Carey, PT3
loan M. Gibbs, PT4
Gregory E. Wiger, PT'
he ground reaction force
during gait is defined as
the force exerted on the
foot by the ground. This
force is threedimensional and can be resolved into three
components: vertical, fore-aft, and
medial-lateral. Normal walking is a
complex biomechanical process and,
during ambulation, each component
of the ground reaction force varies
throughout the gait cycle in regard
to its magnitude and direction. Many
investigators have analyzed one or
more components of the ground reaction force during ambulation in
both normal, healthy subjects (6,8,12,
25) and in individuals with a wide
spectrum of pathological conditions
(3,4,7,9,11,20,25).
Of the three components of
ground reaction force, the vertical
component represents what is commonly referred to as the weight-bearing function of the leg. The magnitude of this vertical component
includes the force required to continually oppose gravity as well as the
force needed to move the body's tenter of gravity up and down with each
step (1522). Thus, the vertical
ground reaction force varies continually from the instant of initial contact
until the foot leaves the supporting
surface and commonly has peak mag-

Although lower extremity immobilization, including restricted knee flexion, is commonly

used in rehabilitation, the effect of angle of knee restriction and walking speed on the vertical
ground reaction forces during gait is unclear. Force plate measurements were made on 36 healthy
males walking at three different speeds when knee flexion was unrestricted and restricted to both
10 and 25'. Analysis of variance and post hoc analyses showed significant increases in four
characteristics of the vertical ground reaction force in the restricted leg and in two characteristics
in the unrestricted leg during walking with restricted knee flexion. Loading rate and unloading rate
for the restricted leg and peak force for both legs showed significant speed-knee flexion restriction
interactions. At the fast walking speed, two significant differences were found between knee flexion
restrictions of 10 and 254 The clinical implications of these findings are that restricted knee flexion
during gait may significantly alter the forces applied to both lower limbs.

Key Words: ground reaction forces, knee restriction, gait

'

Associate Professor, Department of Preventive Medicine and Environmental Health, Physical Therapy
Graduate Program, The University of lowa, 2600 Steindler Building, lowa City, /A 52242
Assistant Professor, Department of Physical Therapy, St. Ambrose University, Davenporf, IA
Physical Therapist, Multicenter Therapy, Spring Lake Park, MN
Physical Therapist, Medical Associates Sports Medicine Center, Dubuque, /A
Physical Therapist, St. loseph's Medical Center, Brainerd, MN

'

nitudes in excess of a subject's body

weight (9,26). The characteristics of
the vertical ground reaction force
can be affected by many factors, such
as body mass and proportions, walking style, coordination and balance,
and, especially, walking speed. Numerous studies have shown that the
characteristics of the vertical ground
reaction force (such as loading rate,
peak force, average force, etc.) are
affected by walking speed (1,2) and
that it is necessary to control this factor in order to make any meaningful
comparisons concerning the vertical
ground reaction force across differ-

ent individuals. Vertical ground reaction forces have been shown to be

reliable and repeatable measures of
gait (10).
One important biomechanical
fhction of the knee is to act as a
shock absorber during the approximately 15" of flexion which occurs
after initial contact of the limb with
the supporting surface (21,%). This
controlled knee flexion, and subsequent gradual extension, plays an
important part in the smooth, efficient movement of the body's center
of gravity during this portion of the
gait cycle (15.19). Clinically, it is ofVolume 25 Nr~mber4 April 1937 JOSPT

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RESEARCH

ten desirable to restrict o r completely

eliminate flexion of the knee in order to allow some healing process to
occur following meniscal and l i p mentous repair, debridement, and
patellar realignment (18). If knee
flexion is completely eliminated, the
normal shock absorption function of
the knee would not be expected to
occur and alterations in the vertical
ground reaction force are likely to
result. Some alterations in the
ground reaction force of the unrestricted leg might also be evident. If,
however, only a partial restriction of
knee flexion is imposed, the knee's
role as a shock absorber at heel strike
could be maintained and the vertical
ground reaction force may be unaffected. In the case of both partial
and total restriction of knee flexion,
it is likely that the ground reaction
force would be altered during other
parts of the gait cycle as the individual tries to compensate for a lack of
normal knee flexion; for example,
vaulting or circumduction may be
used to replace the 60" of knee flexion normally used during .swing
phase. These "compensatory" gait
deviations are likely to be reflected in
altered characteristics of the vertical
ground reaction force in the leg with
restricted flexion as well as in the
unrestricted leg. Although several
studies have investigated vertical
ground reaction forces during normal walking, in persons wearing
heels, in amputees, and with functional rehab braces (7,8), there is
little or no information concerning
the effects of restricting knee flexion.
Lage et al (12) investigated the effect
of unilateral knee immobilization
(brace locked at 0, 10, and 20") compared with normal free walking ( N =
7). Ground reaction force data for
both legs were collected at a self-selected walking speed; however, data
were not reported as ground reaction
force values, but used as input to
equations for determining lower limb
kinetic measures of power.
The purpose of this study was to
measure the effects of restricted knee
JOSIT Vohme 25 Number 4 April 1997

flexion and walking speed on the

vertical ground reaction force during
gait. The first experimental hypothesis was that, at three different walking
speeds, there is a significant difference in loading rate, unloading rate,
peak force, and average value of the
vertical ground reaction force for a
leg with two ranges of knee flexion
restriction vs. no restriction. The second hypothesis was that, at three different walking speeds, there is a significant difference in loading rate,
unloading rate, peak force, and average force of the vertical ground reaction force for the unrestricted leg
during the same conditions.

METHODS
Subjects
Informed consent to participate
in this study was obtained from 36
healthy, male volunteers. All procedures were approved by the Human
Subject9 Review Committee of the
institution. Subjects ranged in age
from 19 to 44 years of age (X = 25.7
years), in height from 1.68 to 1.88 m
(X = 1.79 m), and in weight from
61.8 to 96.4 kg (X = 76.6 kg). Only
males were used to decrease gait variations related to gender (6). Agerelated variations were minimized by
requiring all subject. to fall between
the ages of 18-50 years old (14).
Height and weight were such that all
subjects fell within the fifth and 95th
percentile of the normal population
as found in standard anthropomorphic tables (16). Each subject was
screened to ensure that there was no
history of gait abnormality, lower extremity disorder, or low back disorder. Subject.. wore loose-fitting
clothes and customary walking shoes.

Design
This investigation used a 3 X 3
twefactor, repeated measures design.
Nine separate combinations of the
independent variables of walking

STUDY

speed (three levels) and knee flexion

restriction (three levels) were tested.
The dependent variable, vertical
ground reaction force, was recorded
for both the restricted and unrestricted leg.

Instrumentation
Walking was done on a 12.19 m
0.61 m X .083 m level wooden
walkway with 1.22-m inclines at each
end. Numbered lines, 15.24 cm
apart, were placed on each incline to
serve as starting position indicators
for the subjects. The platform contained a 45.72 cm X 60.96 cm X 8.30
cm force plate offset from the center
of the platform so that it covered
one-half of the width of the walkway.
A black, corrupted, rubber mat covered the platform and force plate.
The outline of the force plate was
discretely marked with black tape to
allow investigators to monitor foot
placement, while not attracting the
subject's attention to the force plate.
Data for one limb were collected as
the subject walked along the walkway
and data for the other limb were collected upon the return. The custommade force plate was constructed of
two steel plates, with a Genisco
AWU250 load cell (Genisco TechnolX

A prefabricated
adjustable knee
orthosis was used as
the method of knee
flexion restriction.
--.-.--

---

- -- ---

ogy Corporation, Northridge, CA)

secured in each comer. The analog
signals from the force plate were amplified by a fourchannel bridge amplifier and digitized at a rate of 250
samples/sec/channel with a microcomputer data acquisition system.
The force plate had a range of 454.5

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RESEARCH STUDY
. .. -~ . . . . .. . . - - . - . ...... -

... .

.-

kg (1000 Ibs) with a resolution of 0.5

kg.
A prefabricated adjustable knee
orthosis was used as the method of
knee flexion restriction. The knee
joint of this device was manufactured
with two settings which restrict m e
tion of the orthotic knee joints to
both 0 and 15" of flexion from full
extension. The orthosis consisted of
medial and lateral uprights, each
with an injection-molded single axis
joint with calf and thigh expansions.
The orthosis was applied with two
0.64 cm foam wraps placed over the
thigh and calf. The two uprights were
placed on the medial and lateral aspects of the leg and adjusted to ensure proper orthosis and knee axis
alignment. The uprights were secured with six Velcro@straps, three
on the thigh and three on the calf.

At the fast walking

speed, the unloading
rate with knee flexion
restricted to 250was
significantly greater
than walking with both
a free knee and with
knee flexion
restricted to lo0.

asking the subject to maximally flex

the knee while standing in the orthotic device. A paired t test was used
to determine if there was a significant
change in the amount of anatomical
knee flexion allowed by the device as
a result of loosening during testing.
The subject then walked on the walkway to become accustomed to the
device. Following accommodation,
subjects were trained to walk at one
of the three predetermined walking
speeds by keeping pace with an investigator who walked alongside and
slightly in front of the subject. Once
a subject could consistently maintain
the desired walking speed, he was no
longer paced. Walking speed was
measured by an investigator using a
stopwatch and was determined by the
time required to travel between two
marks. Each mark was placed 2.5 m
from the center of the force plate,
providing 3.7 m on either end of the
platform for acceleration and deceleration.
To avoid alterations in gait patterns, the subject was not specifically
instructed to step on the force plate.
Instead, the subject's starting position
for each trial was altered to obtain
proper foot contact on the force
plate. The subject was instructed to
keep his head up while walking to
minimize any tendency to target the

knee flexion restriction was also randomized.

When a testing session required a
condition of knee flexion restriction,
the knee orthosis was applied and
manual goniometric measurements
Procedure
were taken at the anatomical knee
Before initiating the study, all
joint to document the range of flexprocedures were approved by the Hu- ion. The arms of the goniometer
man Subjects Review Committee of
were aligned laterally with the long
the institution. Measurements of
axes of the femur and tibia. Conheight, weight, and lower extremity
cerns about brace migration as a relength (from the anterior superior
sult of walking with the orthosis were
illiac spine to the medial malleolus)
addressed by evaluating pre- and
were taken on each subject. Subject
post-test manual goniometric meaweight was recorded from both the
surements on all subjects. The range
force plate and a standard scale.
of motion (ROM) was measured by
Each subject was allowed to walk
on the walkway several times to accommodate to the surface and to the
laboratory area. Following accomme
Peak Farce
dation, the testing required each s u b
ject to walk at three different speeds
for each of the following conditions:
free (nonrestricted, no brace) knee
flexion, restriction from the orthotic
device allowing motion from full extension to 15O of flexion, and restriction from the orthotic device which
was set at 0'. Three different walking
speeds were selected: normal walking
speed (1.3 m/sec) (2.13,15) and a
speed 30% slower (0.9 m/sec) and
30% faster (1.7 m/sec) than normal.
TIME (0.0125 sec)
Speeds and knee restriction conditions were randomized using a Latin
FIGURE 1. Method for determining the four characteristics of the vertical ground reaction force. See text for
details.
Square design. The leg chosen for
Volume 25 Number 4 April 1997 JOSFT

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RESEARCH

force plate. To facilitate this head-up

position, the subject was instructed to
look at an eye-level target posted at
each end of the walkway.
The subject walked on the walkway until three acceptable trials for
each leg at each condition and speed
were recorded. An acceptable trial
met the following requirements:
1) the entire foot struck the force
plate; 2) no part of the other foot
struck the force plate; 3) n o targeting
of the force plate occurred (subject
did not visibly alter his gait pattern to
hit the force plate); and 4) the s u b
ject walked within 50.1 m/sec of the
required speed. Fifty-four trials were
recorded per subject. Trials for one
leg occurred with the subject walking
one direction and for the opposite
leg as the subject returned from the
opposite end.

teristics in each leg, a coefficient of

variation was determined for all samples (25).
Separate analyses of variance
(ANOVA) were calculated for the leg
with restricted knee flexion and for
the unrestricted leg to determine the
effects of subject variability, walking
speed, amount of knee flexion restriction, and any interaction between
speed and knee restriction. Post hoc
Ronferroni-acijusted pair-wise comparisons were done to further examine
significant differences among the various test conditions. In all cases, the
level of significance was adjusted to
maintain an overall value of P < 0.05.

STUDY

RESULTS
Due to technical difficulties, one
subject's data were not used in the
statistical analysis. The paired t test
between the pre- and post-test goniometric measurements demonstrated
no significant difference at the p <
0.05 level, indicating no slippage or
change of knee ROM secondary to
migration. These measurements, however, revealed that the knee flexion
restriction device did not limit knee
motion as intended. Goniometric
measurements of anatomical knee
flexion with the knee flexion restriction device set at 0' revealed a mean

EFFECT OF SPEED
(No Knee Restriction)

Data Analysis
For each leg and each test condition, the mean of the three trials was
calculated for four characteristics of
the vertical ground reaction force:
loading rate, peak force, average
force, and unloading rate (Figure 1).
Rate of loading was determined by
the time it took for the vertical force
to go from 5% to 75% of the s u b
ject's body weight. The value was expressed as body weight/second. Similarly, unloading rate was determined
by the time it took for the vertical
ground reaction force to go from
75% to 5% of the subject's body
weight and was also expressed in
units of body weight/second. Peak
force was measured as the highest
vertical ground reaction force which
occurred anytime during the stance
phase and was expressed in percent
body weight. No attempt was made to
determine whether the peak force
occurred in early or late stance. Average force was determined using all
the values within the 5% loading and
5% unloading thresholds and was
also expressed in percent body
weight. To assess the variability of
vertical ground reaction force charac-

JOSPT Volume 25 Number 4 April 1997

0
L

.-0

EFFECT OF KNEE RESTRICTION

(At 1.3 Mlsec Walking Speed)

Time (0.083 sec)

FIGURE 2. Sample force a.time recordings from a typical subject showing the effects of walking speedand knee
flexion restriction.

Source
Subject
Knee restriction
Walking speed
Restriction
Error speed

df

SS

Restricted Knee

p>F

34 9699.1
6.85 0.0001
2 3673.1 44.08 0.0001
2 31992.8 383.96 0.0001
3.29 0.0117
4
548.6

a.

Loading Rate

'" 1

c.

Peak Force

50

b.

Unloading Rate

272 11331.9

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TABLE 1. Analysis of variance of loading rate ior the

leg with knee flexion restriction.

range of flexion of 9.6" with a standard deviation of 2.3". With the orthosis set at 15" of flexion, mean anatomical range of flexion was actually
23.9" with a standard deviation of
5.1". Based on the goniometer measurements, the three levels of the independent variable of knee flexion
restriction were actually free (no restriction or orthotic device), approximately 25" of knee flexion, and a p
proximately 10" of knee flexion
rather than the intended free, 15",
and 0".
Walking speed was found to be a
significant main effect for all measures for both legs. Figure 2 shows
data from a typical subject qualitatively showing the effects of walking
speed and knee flexion restriction.
Only ANOVA tables of vertical
ground reaction force characteristics
are included for which there was a
significant interaction present between walking speed and knee flexion restriction (restricted leg: loading
rate, unloading rate, and peak force;
unrestricted leg: peak force). The
average coefficient of variation for all
vertical ground reaction force characteristics in both legs was 13.55%.

Loading Rate
The ANOVA for the restricted
leg demonstrated statistical significance for the main effects of speed
and knee flexion restriction and for
speed-knee restriction interaction
(Table 1). There were significant differences among all walking speeds.
For both normal (1.3 m/sec) and fast
(1.7 m/sec) walking speeds, post hoc
analysis revealed significant differ-

Walking Speed (mlsec)

d.

Average Force

Walking Speed (mlsec)

FIGURE 3. Effects of walking speed and knee flexion restriction on mean values (N = 35, three trials for each
subject) of four characteristics of the vertical ground reaction force from the leg with restricted knee motion:
a) loading rate, b) unloading rate, cl peak force, and d) average force.

ences in loading rate between walking with free knee flexion and walking with knee flexion restricted to
both 10 and 25". For the slow walking speed (0.9 m/sec), there was a
difference between walking with a
free knee and walking with knee flexion restricted to 10" (Figure 3a).
The ANOVA for the unrestricted
leg demonstrated statistical significance for the main effects of speed
(p = 0.0001) and knee flexion restriction (p = 0.0037). No interaction
was found. Post hoc analysis of the
main effect of speed revealed significant differences in loading rates
across all speeds. No significant differences were found between free
walking and walking with either
amount of knee flexion restriction
(Figure 4a).

Unloading Rate
For unloading rate, the ANOVA
for the restricted leg demonstrated

main effects for speed, knee motion

restriction, and an interaction between the two (Table 2). Post hoc
analysis showed a significant interaction in unloading rate at the fast
walking speed (1.7 m/sec). At this
speed, the unloading rate with knee
flexion restricted to 25" was significantly greater than walking with both
a free knee and with knee flexion
restricted to 10". There was no difference between the free knee and the
10" restriction condition (Figure 3b).
For the unrestricted leg, the only
significant finding for unloading rate
(p < .OOl) was a difference due to
Source
Subject
Knee restriction
Walking speed
Restriction

df

SS

p>f

34 299.3
7.56 0.0001
2 21.4
9.18 0.0001
2 1238.1 531.90 0.0001
4 21.7
4.67 0.001;

x speed

IError

272 316.6

TABLE 2. Analysis of variance o i unloading rate for

the leg with knee flexion restriction.
Volume 25 Number 4 April 1997 JOSPT

RESEARCH

Average Force

Unresitricted Knee
a.

Loading Rate

b.

Unloading Rate

The ANOVA for the restricted

leg showed statistical significance for
02s d.0 n o x i o n
the main effects of walking speed
lOd.0noXlOn
(p = 0.0001) and knee flexion restriction (p = 0.0001). No speed-knee
flexion restriction interaction was
demonstrated. Post hoc analysis for
the main effect of speed showed significant differences in average
force
among all speeds. Post hoc analysis
for the effect of knee flexion restricc. Peak Force
d. Average Force
tion revealed significant differences
,
I50
1
T
T T between walking with free knee flexion and walking with both 10 and 25"
of knee flexion restriction at all three
walking speeds (Figure 3d).
The ANOVA for the unrestricted
leg demonstrated statistical significance for the main effects of speed
(p = 0.0001) and knee flexion re(p = .0001). No interaction
striction
0.9
1.3
1.7
0.9
1.3
1.7
was
observed.
Post hoc analysis for
Walking Speed ( d s e c )
Walking Speed ( d s e c )
the effect of speed revealed signifiFIGURE 4. Effects of walking speed and knee flexion restriction on mean values (N = 35, three trials for each cant differences in average force
subject) of four characteristics of the vertical ground reaction force from the unrestricted leg: a) loading rate,
among all speeds. Post hoc analysis
b) unloading rate, c) peak force, d) average force.
for the effect of knee restriction demonstrated significant differences beThe ANOVA for the unrestricted
the three different walking speeds
tween walking with free knee flexion
leg demonstrated statistical signifi(Figure 4b).
and walking with both 10 and 25" of
cance for main effects of speed and
knee flexion restriction at all three
knee
flexion
restriction
as
well
as
for
walking
speeds (Figure 4d).
Peak Force
speed-knee flexion restriction interacThe ANOVA for the restricted
tion (Table 4). Post hoc analysis reDISCUSSION
leg demonstrated statistical signifivealed a significant difference becance for the main effects of speed
tween walking with free knee flexion
This study hypothesized signifiand knee flexion restriction as well as and walking with both 25 and 10" of
cant changes in four characteristics
for speed-knee flexion restriction inknee flexion restriction during the
of the vertical ground reaction force
teraction (Table 3). Post hoc analysis fast walking speed. At the fast walking
due to two different levels of knee
demonstrated significant differences
speed, the two conditions of knee
flexion restriction. The effects and
between free knee flexion and the
flexion restriction were also different possible interactions of walking speed
two forms of knee flexion restriction
were also examined. Positive findings
from each other (Figure 4c).
at both the normal and fast walking
occurred for both levels of knee flexspeeds (Figure 3c).
ion restriction as well as for walking
speed. In the restricted leg, all four
vertical
ground reaction force characSource
df
SS
F p>F
Source
df
SS
F p>F
teristics were significantly affected by
Subject
34 7926.8 5.70 0.0001
Subject
34 8306.7 5.98 0.0001
restriction of knee flexion. In the
Knee restriction
2 788.6 9.64 0.0001
Knee restriction
2 2207.1 26.97 0.0001
unrestricted leg, peak force and averWalking
speed
2
58870.2
719.42
0.0001
Walking speed
2 65815.2 804.23 0.0001
Restriction
4 758.6 4.64 0.0012
Restriction
4 644.2 3.94 0.0040
age force were significantly affected.
Therefore, the research hypotheses
27211128.9
Error
27211129.7
Error
regarding the effects of knee flexion
restriction were accepted. All four
. TABLE 4. Analvsis of variance of peak force for the
TABLE 3. Analysis of variance of peak force for the
vertical ground reaction force characunrestricted leg.
leg with knee flexion restriction.
r n h n k r m

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l5

STUDY

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241

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RESEARCH

STUDY

teristics in both legs were significantly

affected by walking speed and, therefore, the research hypothesis regarding the effects of speed was also accepted. The finding that speed
significantly affects the vertical
ground reaction force is in agreement with previous studies (l,2,17).
The finding that restricted knee flexion has significant effects on the vertical ground reaction force in both
legs is a previously unreported result.
Schuit et a1 (20) reported an average increase of 4.6% in the peak
vertical ground reaction force as a
result of installing heel lifts in 18 s u b
jects with leg length discrepancies.
Balmaseda et al (3) reported a mean
increase of 20% in the peak vertical
ground reaction force in healthy volunteers wearing ankle-foot orthoses
compared to walking without an orthosis. Carmines et al (4) measured
ground reaction forces in subjects
with taped ankles and found decreased heel impulses as a result of
the taping.
Inferences may be made relative
to the work of Lage et al (12), who
noted changes in kinetic values for
both legs due to knee flexion restriction. Compared with the earlier
study, this study reports the vertical
ground reaction forces for a larger,
homogenous sample size (35 subjects
vs. 7), at three walking speeds rather
than one, and using an orthosis that
allowed motion within a restricted
range rather than locking the knee at
a fixed angle. In the previous study,
significant increases, primarily in ankle and hip mechanical work, were
reported early in the gait cycle and
during push-off for the braced leg (0
and 20" conditions). The current
study found changes in loading rate
and peak force of the restricted leg
that would appear to correspond to
the prior study's increases in work at
the hip and ankle during the early
portions of the gait cycle, where
greater peak moments were reported
to have been reached quicker following heel contact for the 0 and 20"
braced conditions. Although the pre-

vious study reported few changes in

the unrestricted limb, citing high intersubject variability, their changes
during push-off may correspond to
the changes in unloading rate found
in the current study. Implications
may be that the unrestricted limb was
able to compensate for the altered
mechanics, although the increased
peak forces seen in the current study
may be reflective of the previous
study's proposed increases in the unrestricted limb due to "vaulting" to
clear the restricted limb.
As stated earlier, a normally functioning knee serves as a shock a b
sorber in early stance phase and then
assists in a controlled, smooth transition of the center of gravity toward
the contralateral leg during the pre.swing portion of stance phase (21).
When knee flexion restriction was
imposed, alteration of these normal
functions occurred. Increased walking speed tended to accentuate these
alterations. In the restricted leg, reduced ability to absorb shock was evident by a higher loading rate. Associated with this increased rate of limb
loading, the peak force that was ultimately attained was also increased.
Both of these factors combined to
produce a significantly higher average force on the leg throughout the
entire stance phase. The unloading
rate was only affected by restriction
of knee flexion at the fast walking
speed, possibly because at the slower
speeds the subjects' unrestricted leg
was able to adequately compensate
during the double support phase. In
the unrestricted leg, an increased
peak force and average force occurred with restriction of knee flexion. Kinematic changes in gait during
knee restriction have been reported
previously (12). An abnormal shifting
of the center of gravity toward the
unrestricted side may have occurred
in order to increase clearance for the
restricted limb during swing phase or
there may have been changes in step
or stride lengths. Loading and unloading rates in the unrestricted limb

were not significantly affected by restriction of knee flexion.

In theory, restricting knee flexion
to only the last 15' should not affect
normal knee mechanics during early
stance phase. Complete restriction of
knee flexion, however, could be expected to have an important effect.
The results of this study indicate a
vend in this direction (Figure 3), but
the only significant differences between 25 and 10" of knee flexion restriction were for unloading rate at
the fast walking speed and peak force
in the unrestricted limb. One reason
that more significant differences between the two amounts of knee flexion restriction were not found in this
study may be the limitations of the
orthosis used for knee flexion restriction. When the orthosis was set at 0,
an average of approximately 10" of
flexion was actually allowed at the
anatomical knee joint. This range of
flexion approximated the nominal
15" normally occurring during early
stance phase. An orthosis setting of
15" of flexion actually allowed 25" of
flexion at the anatomical knee joint.
The findings of lack of the orthotic
device to accurately restrict knee m e
tion support the findings of others.
Stevenson et al (24) reported up to a
20" increase in dynamic knee ROM
while attempting to prevent the last
30" toward terminal extension (braces limited to 30" of full knee flexion). Cawley et al (5) reported between a 6.4 and 18.6" increase in
ROM in various braces attempting to
limit extension ROM. Even though
no significant differences were found,
the results of this investigation do
indicate a trend that the more knee
flexion is restricted, the greater the
effects on the vertical ground reaction force.
All ROM measurements were
taken statically and perhaps even
greater dynamic ranges occurred during gait. The use of an electrogoniometer in future studies could assist
in determining these dynamic ranges.
This was not an original purpose of
this study but arose due to the invesVolume 25 Number 4 April 1997 JOSPT

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.-.-

tigators concern for ensuring no influence due to brace migration.

Walking speed-knee flexion restriction interaction occurred in the
restricted leg for the dependent variables of loading rate, unloading rate,
and peak force. As speed increases,
more knee flexion is needed during
early stance phase. Knee restriction at
faster walking speeds led to a significantly increased loading rate. Associated with this increased loading rate,
the peak force was also significantly
increased with faster walking speeds.
Interaction in the unrestricted leg
was found in the peak force measurement. When speed is increased, more
flexion and quicker movements are
required. Therefore, at the faster
walking speed, the unrestricted leg
was nearing its fullest capacity for
movement, allowing less latitude for
compensation. It should also be
noted that there may be changes in
ground reaction forces in the fore-aft
and medial-lateral directions with
knee immobilization.

Clinical Implications
The findings of this study have
several implications for the clinical
use of devices intended to restrict
knee flexion. When the knee is restricted as a component of a treatment program, gait mechanics are
altered. A relationship exists between
increased ground reaction force characteristics and mechanical stresses on
the limb. Since vertical ground reaction force changes were observed in
both legs, this implies that each leg
experiences increased stress as the
result of the use of a knee flexion
restriction device. In some instances,
increased stress could be helpful to
facilitate bone and cartilage develop
ment or repair, such as following
fractures. In many other cases, however, a knee flexion restriction device
is applied as a protective measure
while injured or surgically repaired
structures are healing (ie., following
meniscal or ligamentous repair, patelJOSm Volume 25 Number 4 April 1997

-------- - -..----.------..

-----

R.-E-.S..E-A- R-C H--S-T-.U D-Y.

striction with patients that have acute

lar realignment, etc.). In these circumstances, clinicians might consider and chronic pathologies must be examined. Since the restriction device
secondary methods of decreasing the
allowed
more knee flexion than that
vertical ground reaction force. For
indicated
by the orthosis design,
example, a patient might be inmore accurate forms of knee flexion
structed to walk at slower speeds
restriction should be investigated.
rather than his or her normal speed
Dynamic knee motions while wearing
or the speed of peers or associates.
This study clearly supports other
a knee motion restriction device
studies showing that walking speed is should be done to evaluate the actual
a major determinant of vertical
knee motions allowed by various deground reaction force characteristics
vices. These motions are likely to be
greater than those reported in this
(2,17). If treatment of an injury allows a partial range of knee flexion,
study. Assistive devices may be useful
the use of a restrictive device utilizing in partially unloading the limb and
reducing mechanical stresses. Cushthis range would seem preferable to
using more restrictive immobilization ioned heels, rocker bottom soles, or
than is necessary. In using any device, similar special shoe modifications
however, it is important that the clini- may prove useful in "normalizingw
vertical ground reaction force characcian accurately check the actual anateristics in patients using a knee flex.-....,..,-. .. . ...,. -- .. .-....- ..,--.
ion restriction device.

It is important that the

clinician accurately
check the actual
anatomical joint
motion allowed by the
device rather than
relying on the
manufacturer's
preset limits.
tomical joint motion allowed by the
device rather than relying on the
manufacturer's preset limits. A static
discrepancy of approximately 10" was
found with the device used in this
study and there is no reason to assume that it is different from other
devices designed for the same purpose.
Several future studies are indicated by the results of this investigation. A broader range of age, gender,
and anthropometric parameters
needs to be investigated. Additionally, the effects of knee flexion re-

CONCLUSIONS
The results of this study indicate:
I) the characteristics of loading rate,
peak force, unloading rate, and average value of the ground reaction
force in both limbs were significantly
affected by walking speed; 2) in the
restricted leg, all four vertical ground
reaction force characteristics were
significantly affected by knee flexion
restriction; 3) in the unrestricted leg,
peak and average force were significantly affected by knee flexion restriction; and 4) only at the fast walking speed, and only for unloading
rate in the restricted leg and peak
force in the unrestricted leg, was
there a significant difference between
walking with knee flexion resmcted to
25" and knee flexion resmcted to 10".
The results of this study are important to clinicians who apply external devices to restrict knee flexion as
part of patient treatment. The vertical, weight-bearing component of the
ground reaction force in both the
restricted and unrestricted legs is significantly affected by application of
such a device. Patients should be
counseled that walking speed is a

very important factor affecting forces

in both legs, especially when normal
knee flexion is restricted. In particular, patients should be instructed to
limit their walking speed to counteract the increases in mechanical stress
that result from walking with restricted knee flexion.
JOSPT

ACKNOWLEDGMENT

Journal of Orthopaedic & Sports Physical Therapy

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Copyright 1997 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

The authors wish to express their

appreciation to Dr. John Rosecrance
and Dr. Chris Zimmennann for their
help in the final preparation of the
manuscript.

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