a state of complete physical, mental, and social well-being, and not just the absence of disease or infirmity

a state of complete physical, mental, and social well-being, and not just the absence of disease or infirmity

1. LITERATURE REVIEW OVER DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE

2. INTRODUCTION The knee complex is one of the most frequently injured joints in the human body. The knee complex is composed of two different articulations located within a single joint capsule: the Patellofemoral joint and the Tibiofemoral joint. The patellofemoral joint is the articulation between the posterior patella and the distal femur. The tibiofemoral joint is the articulation between the distal femur and the proximal tibia. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 2

3. INTRODUCTION Q angle : The orientation of the quadriceps resultant pull with respect to the pull of the patellar tendon provides information about the net force on the patella in the frontal plane. The Q-angle is the angle formed between a line connecting the anterior superior iliac spine to the midpoint of the patella (representing the direction of pull of the quadriceps) and a line connecting the tibial tuberosity and the midpoint of the patella. A Q-angle of 10° to 15° measured with the knee either in full extension or slightly flexed is considered normal. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 3

4. INTRODUCTION Ankle Joint : The term ankle refers specifically to the talocrural joint, that is the articulation between the distal tibia and fibula proximally and the body of the talus distally. The ankle is a synovial hinge joint with a joint capsule and associated ligaments. It is generally considered to have a single oblique axis with one degree of freedom around which the motions of dorsiflexion / plantarflexion occur. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 4

5. INTRODUCTION OA Knee with Q Angle : The Q-angle provides an estimate of the vector force between the quadriceps muscle and patellar tendon. A stronger vastus lateralis pulls the patella laterally, resulting in a larger Q-angle , while a stronger vastus medialis pulls the patella medially, resulting in a smaller Q-angle. Therefore, the Q-angle is an indicator of the imbalance between components of the quadriceps muscle. A Q-angle in excess of 20° may lead to knee joint instability and lateral patella tracking. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 5

6. INTRODUCTION OA Knee with foot pronation : . The medial compartment of a normal knee joint bears approximately 70% of body weight whereas the lateral compartment bears the 30% weight. The GRF trajectory passes medially and posterior to the knee joint. Any degenerative changes in knee OA leads to shifting of this knee adduction moment to that particular compartment which is directly correlated with joint space narrowing, joint capsule loosening and levels of pain and functional limitation. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 6

7. INTRODUCTION Pronated foot is a foot posture in which the calcaneus goes in valgus position, whereas the metatarsal region is in pronation. Change in foot posture may cause increased mechanical rotational stress on the knee joint and the higher degree of knee OA may also affect foot motion during walking which may lead to a compensatory response to allow typical function of the foot during ambulation and accelerates the degenerative changes at the knee joint. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 7

8. NEED OF STUDY OA knee is a most common condition which is seen in elderly people, which causes many problems in daily routine life and as severity of OA increases there is changes in joint cartilage, osteophytes formation, which leads to many problems like altered biomechanics of lower limb, it leads to deviation in alignment of lower limb like frontal plane knee alignment (deviation in Q- angle) and foot posture (pronated or supinated foot). Deviated knee alignment and foot posture leads to further risk like, increase joint loads, affect the mechanical efficiency of muscles, proprioceptive orientation and feedback from the hip and knee and thus resulting in altered neuromuscular control of the lower extremities. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 8

9. NEED OF STUDY This all changes leads to decrease functional ability and difficulty in ADLs. Hence, preventive measures should take in patient with osteoarthritis, which helps to change in altered biomechanics and improves functional abilities and ADLs. This changes influences decision making and assessing outcomes of the various operative procedures like high tibial osteotomy and total knee replacement. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 9

10. AIMS OF THE STUDY The present study aimed to correlate the quadriceps angle deviation and foot posture deviation in osteoarthritis knee patients. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 10

11. OBJECTIVES of study Osteoarthritis is a progressive musculoskeletal condition leading to disability. Malalignment of knee joint is one of the main predisposing factors for the onset and progression of osteoarthritis. Study demonstrated that MTFOA and PFOA are more likely to be associated with Varus alignment (decrease in Q-angle) and LTFOA and TF/PFOA with valgus alignment (increase in Q-angle). MTFOA Knee showed more pronated foot and LTFOA showed more supinated foot. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 11

12. HYPOTHESIS Null hypothesis (Ho) There is negative co-relation between osteoarthritis with deviation of Q-angle. There is negative co-relation between osteoarthritis with deviation of foot posture. Alternative hypothesis (H1) There is positive co-relation between osteoarthritis with deviation of Q-angle. There is positive co-relation between osteoarthritis with deviation of foot posture. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 12

13. MATERIALS AND METHOD An electronic search was conducted on different sites, pubmed , cochrane , medline , jospt , ResearchGate, etc. Publications were researched using the key words: correlation of “Q-angle” & “foot deviation” in “osteoarthritis knee”. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 13

14. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 14

15. RESULT STUDY CHARACTERISTICS 15 studies included a total of 1175 participants of 14 researches from which 1033 participants were diagnosed with osteoarthritis knee , 9825 participants of meta- analysis and systemic review from which 5328 participants has osteoarthritis knee, with mean age 62.68 year & BMI 28.13 Kg/m 2 . This studies includes a patients with OA knee from which 8 studies were included a patients with combined tibiofemoral and patellofemoral OA, 7 included patients with tibiofemoral OA, 1 included patients with patellofemoral OA. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 15

16. RESULT From this all studies, 7 studies confirms that patients with OA knee develops deviation in Q-angle, 7 studies confirms that patients with OA knee develops foot posture deviation and 2 of them concluded that foot deviation and Q-angle deviation are correlated in patients with osteoarthritis knee. Analysis of all studies done and its characteristics included in table 1 & 2. It includes a number of participants, male, female, mean age, BMI, criteria for diagnosis of OA, radiographic severity of OA, type of OA, deviation of Q-angle & foot posture deviation. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 16

17. TABLE 1: Study characteristics: articles related to Q-angle deviation in osteoarthritis knee. Study Prachita W. et al. (2018) Joyce A.C. Van Tunen et al. (2018) Ayşe Aydemir EKİM et al. (2017) Shuhei Otsuki et al. (2016) No. of subject T=84 OA=42 H= 42 T=9825 OA=5328 H=4497 T=68 OA=68 H=0 T=85 OA=85 H=0 Male NR NR Female 84 NR 68 NR Mean age (year) 55.22±4.32 63.5 59.8±6.8 NR BMI (Kg/m 2 ) NR 29.1 30.6±4.8 NR Criteria for diagnosis ACR clinical Criteria& Radiograph Radiographic & symptomatic WOMAC Scale Radiographic Radio- graphic severity K/L grade 1-4 K/L grade ≥2 NR K/L grade 1-4 Type of OA Patellofemoral/ Tibiofemoral Tibiofemoral Patellofemoral/ Tibiofemoral Patellofemoral Q angle Deviation High Q-Angle M= low Q angle L= high Q angle M/L=high Q angle High Q-Angle Low Q-Angle DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 17

18. Study M. Henriksen et al. (2012) A. J. Teichtahl et al. (2008) Akinbo SRA et al. (2004) F. Cicuttini et al. (2004) No. of subject T=143 OA=143 H=0 T=99 OA=99 H =0 T=40 OA=20 H=20 T=117 OA=117 H=0 Male 63 40 10 68 Female 80 59 30 49 Mean age (year) 64.4 63±10 50.7±8.89 67.0±10.6 BMI (Kg/m 2 ) 28.6 28.9±5.1 NR 28.7±5.1 Criteria for diagnosis MRI X-RAY ACR radiographic & clinical criteria Clinical & radiographic WOMAC score >20mm, X-RAY, MRI Radio- graphic severity K/L grade 1-4 K/L grade 2 K/L grade 1-4 K/L grade 1-4 Type of OA Tibiofemoral Patellofemoral/ Tibiofemoral Patellofemoral/ Tibiofemoral Tibiofemoral Q angle Deviation Related to change in cartilage thickness High Q-angle High Q-angle M= low Q-angle L=high Q-angle DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 18

19. Study Hirotaka Iijima et al(2018) Dr. Shalmali S. Surlakar et al. (2017) Hiroshi Ohi et al. (2017) F.E. Abourazzak et al. (2014) No. of subject T=68 CPFOA=38 ITFOA=30 T=100 OA=100 H=0 T=88 OA=88 H=0 T=180 OA=100 H=80 Male 17 25 NR 38 Female 51 75 NR 142 Mean age (year) 74.69±7.785 61.63±9.654 74.8±7.58 59.68±7.64 BMI (Kg/m 2 ) 24.14±3.753 28.95±35.72 24.3±3.54 30.89±4.94 Criteria for diagnosis Radiographic ACR criteria & Radiographic Radiographic Radiographic Radio- graphic severity K/L grade ≥ 2 K/L grade 1-4 K/L grade ≥ 1 K/L grade 1-4 Type of OA Patellofemoral / tibiofemoral Tibiofemoral OA Tibiofemoral OA Medial compartment Tibiofemoral OA Foot Posture Inverted rearfoot posture M= Pronated foot L= Supinated Foot Calcaneus valgus Pronated Foot TABLE 2: Study characteristics: articles related to foot posture deviation in osteoarthritis knee. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 19

20. Study Pazit Levinger et al. (2013) Necati Balci and Lale Cerrahoglu(2012) P. Levinger et al. (2010) No. of subject T=32 OA=32 H=0 T=39 OA=39 H=0 T=32 OA=32 H=0 Male 16 11 NR Female 16 28 NR Mean age (year) 65.8±7.5 51.53±11.89 65.84±7.57 BMI (Kg/m 2 ) NR 30.5±4.9 24.79±11.29 Criteria for diagnosis Clinical, Radiographic Radiographic Radiographic Radiographic severity K/L grade ≥ 2 K/L grade 1-4 K/L grade 1-4 Type of OA Medial compartment Tibiofemoral OA Patellofemoral / Tibiofemoral Medial compartment Tibiofemoral OA Foot Deviation Pronated Foot Pronated Foot Pronated Foot DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 20

21. ANALYSIS OF STUDIES TABLE 3: analysis of studies shows Q-angle deviation . Type of OA High Q-angle (no. of studies) No deviation in Q-angle (no. of studies) Low Q-angle (no. of studies) Medial tibiofemoral OA 3 Lateral tibiofemoral OA 3 Medial/Lateral tibiofemoral OA 1 Patellofemoral OA 1 Patellofemoral/ tibiofemoral OA 4 DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 21

22.   4           3   3                                                           1   1               0 0   0 0 0 0       0 0 Fig.1: number of studies shows high, low or no deviation in Q-angle DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 22

23. RESULT Result concludes 100% deviation in Q-angle seen in osteoarthritis knee as severity of OA increases. It means the deviation in Q-angle is directly proportional to severity of arthritis and cartilage changes. 75% of studies conclude that there is increase in Q-angle, in which 37.5% were noted in LTFO, 12.5% in media-lateral compartment TFOA and 50% in TF/PFOA, which means prevalence of increase in Q-angle is more in combined TF/PFOA. 25% of studies conclude that there is decrease in Q-angle, in which 75% were noted in MTFOA and 25% in PFOA. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 23

24. TABLE 4: Analysis of studies shows deviation in foot posture Type of OA Supinated Foot Posture Pronated Foot Posture Inverted Foot posture Medial tibiofemoral OA 5 Lateral tibiofemoral OA 1 Medial/Lateral tibiofemoral OA Patellofemoral OA Patellofemoral/ tibiofemoral OA 1 DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 24

25. RESULT 2 studies concludes, lateral compartment osteoarthritis shows supinated foot posture & genu Valgum (increase in Q-angle) of knee, medial compartment osteoarthritis shows pronated foot posture & genu varum (decrease in Q-angle) of knee. Pronated foot posture is related to tibiofemoral osteoarthritis mostly medial compartment involvement. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 25

26. Number of studies shows foot posture deviation 5 1 0 0 0 0 0 0 0 0 1 MTFOA LTFOA TFOA PFOA TF/PFOA Supinated foot Pronated foot Inverted foot Fig. 2 : number of studies shows pronated, supinated or inverted foot. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 26

27. RESULT Result concludes 100% deviation in foot posture seen in osteoarthritis knee as severity of OA increases. It means the deviation in foot posture deviation is directly proportional to severity of arthritis and changes in alignment of lower limb. 71.4% of studies conclude that there is pronated foot posture is seen, which is related to MTFOA. 14.3% of studies conclude that there is supinated foot posture, which is related to LTFOA. 14.3% of studies conclude that there is inverted foot posture, which is related to TF/PFOA. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 27

28. DISCUSSION This literature review shows that, Q-angle deviation and foot posture deviation is present in osteoarthritis knee. Most of studies conclude that high Q-angle and pronated foot posture is seen in osteoarthritis knee. This literature review includes 15 studied out of which 14 studies were researches conducted over patients with osteoarthritis and 1 is systemic review & meta-analysis. 8 studies conclude that Q-angle deviation is present in patient with osteoarthritis out of which most of studies conclude increase in Q-angle. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 28

29. DISCUSSION High Q-angle is present in patients with combined tibiofemoral & patellofemoral osteoarthritis & isolated tibiofemoral osteoarthritis, which is associated with changes in cartilage thickness. Low Q-angle is found in patients with osteoarthritis with medial compartment involvement. Most of the patient shows increases knee adduction moment which leads to loss of lateral cartilage thickness, and results in genu Valgum (increase in Q- angle). 2 studies conclude that decrease in Q-angle is associated with loss of medial cartilage thickness and increase in Q-angle is associated with loss of medial cartilage thickness. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 29

30. DISCUSSION Patellofemoral osteoarthritis leads to decrease in Q-angle, due to change in tibiofemoral angle. Tibiofemoral angle is significantly larger in patients with osteoarthritis knee; it increases as severity of patellofemoral arthritis increases. And this deviation leads to decrease in Q-angle. This study has low evidence about correlation of Q-angle deviation with BMI. It has been reported that a 10% increase in the Q-angle will increase the stress on the patellofemoral joint by 45%. There is also alteration in hamstring quadriceps ration, due to alteration in muscle strength, it also leads to deviation in alignment (Q-angle). DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 30

31. DISCUSSION This study found pronated foot posture is noted in most of patients with osteoarthritis knee. Pronated foot posture is associated with tibiofemoral osteoarthritis with involvement of medial compartment. Most of studies are done on patients with tibiofemoral osteoarthritis and concluded that lateral compartment OA leads to supinated foot and medial compartment involvement leads to pronated foot. 2 studies provides evidence that in patients with tibiofemoral osteoarthritis with medial compartment involvement, genu varum & pronated foot posture is noted, and in patients with tibiofemoral osteoarthritis with lateral compartment involvement, genu valgum & supinated foot posture is noted. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 31

32. DISCUSSION These changes in foot posture are strongly associated with altered biomechanics due to knee osteoarthritis (disturbances of weight bearing and walking pattern occur in patients, which leads to changes in the mechanical alignment of lower limb and dynamic function of the foot). These studies prove that deviated foot posture is associated with internal tibiofemoral arthritis. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 32

33. DISCUSSION Deviated knee alignment and foot posture leads to further risk like, increase joint loads, affect the mechanical efficiency of muscles, proprioceptive orientation and feedback from the hip and knee and thus resulting in altered neuromuscular control of the lower extremities. Hence, preventive measures should take in patient with osteoarthritis, which helps to change in altered biomechanics, and helps to prevent deviation in Q-angle and foot posture. Changes influences decision making and assessing outcomes of the various operative procedures like high tibial osteotomy and total knee replacement. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 33

34. CONCLUSION In this study, we found that deviation of Q-angle and foot posture is present in osteoarthritis knee which is associated with type of osteoarthritis. Mostly increase in Q-angle is found which is associated with combined patellofemoral/tibiofemoral osteoarthritis or tibiofemoral osteoarthritis (lateral or medial-lateral). Decrease in Q- angle is found in tibiofemoral osteoarthritis with lateral compartment involved or patellofemoral arthritis. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 34

35. CONCLUSION Pronated foot posture is found mostly in osteoarthritis, which is associated with tibiofemoral arthritis (medial or medial-lateral). Supinated foot is found which is associated with tibiofemoral arthritis with lateral compartment involved. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 35

36. LIMITATION OF STUDY This study provides low evidence of other factors affecting the deviation of Q-angle and foot posture i.e. BMI, height, weight, waist-hip ratio, gait pattern, posture, standing habits, work, etc. Quantitative data of deviation in Q-angle and foot is not found. Method of measurement of Q-angle and foot posture is different so specific deviation cannot found. Low evidence of reason of deviation in Q-angle and foot posture is found. Degree of severity of osteoarthritis is not same in all studies DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 36

37. FUTURE SCOPE Study can be more specified by taking other criteria i.e. BMI, height, weight, specific severity of osteoarthritis, gait pattern, posture, standing habits, etc. Study over specific deviation of Q-angle and foot deviation, with reliable measures. Study over more number of literature review and with specific reliable measures for Q- angle and foot posture deviation. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 37

38. FUTURE SCOPE Also can more specify over participants work in whole day leads to change in biomechanics, leads to deviation in Q-angle and foot posture. Study over prevalence of increase severity of osteoarthritis due to Q-angle deviation or altered foot posture. Study over the prevalence of deviation in Q-angle and foot posture with ongoing physical therapy treatment. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 38

39. REFERENCES Pamela K. Levangie , Cynthia C . Norkin Joint Structure and Function, Philadelphia: F.A Davis Company, 2011. C kisner and a. c. lynn , therapatic exercisefoundation and technique, philadelphia : F A Davis Vompany , 2012. C.B. V. 2., Human Anatomy, CBS Publishers, 2010. F. A. H, “Pes Cavus and Pes Planus,” vol. 67, no. 5, pp. 688-694, 1987. A.D. A. A. K.L. Moore, “Clinically oriented anatomy,” pp. 710-2, 2006 S.Standring , “The anatomical bases of clinical practice,” in Gray's Anatomy, 2008, pp. 2639-42,2660-6. B. H. e. a. Hosl M, “Does accessive flat foot deformity affact function? A comparision between symptomatic & asymptomatic flat feet using oxfard foot model,” Gait & Posture, no. 17/05/2013, pp. 23-28, 28 September 2014 T.T. Rodrigues P, “ Evaluating runners with and without anterior knee pain using the time to contact the joint complexes’ range of motion boundary.,” Gait and Posture, 2013. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 39

40. REFERENCES T. T. H. J. Rodrigues PA, “ Runners with anterior knee pain utilize a greater percentage of their available pronation range of motion.,” Journal of Applied Biomechanics, p. 141–6, 2013. Prachita Walankar , Vrushali Panhale , Anudnya Koli Evaluation of Quadriceps angle in women with unilateral osteoarthritis of the knee IJAMSCR Volume 6 , Issue 2 Apr - Jun – 2018. Akinbo, Alimi ,Noronha Relationship Between Bilateral Knee Joint osteoarthritis and the Quadriceps (Q )- angle SA Journal o f Physiotherapy 2004 V o l 60 No 3. Pazit Levinger, Hylton B Menz , Mohammad R Fotoohabadi , Julian A Feller, John R Bartlett, Neil R Bergman Foot posture in people with medial compartment knee osteoarthritis Levinger et al. Journal of Foot and Ankle Research 2010. DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 40

41. Thank you DEVIATION OF QUADRICEPS ANGLE AND FOOT POSTURE IN OSTEOARTHRITIS KNEE 41