Clinical Biomechanics 27 (2012) 711–718

Contents lists available at SciVerse ScienceDirect

Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

In vivo measurement of shoulder joint loads during walking with crutches

P. Westerhoff a,⁎, F. Graichen a, A. Bender a, A. Halder b, A. Beier b, A. Rohlmann a, G. Bergmann a
a
Julius Wolff Institut, Charité – Universitätsmedizin Berlin, Germany
b
Klinik für Endoprothetik Sommerfeld, Beetz-Sommerfeld, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: Following surgery or injury of the lower limbs, the use of walking aids like crutches can cause
Received 5 August 2011 high loads on the shoulder joint. These loads have been calculated so far with computer models but with
Accepted 13 March 2012 strongly varying results.
Methods: Shoulder joint forces and moments were measured during crutch-assisted walking with complete
Keywords: and partial unloading of the lower limbs. Using telemeterized implants in 6 subjects axillary crutches and
Shoulder joint
forearm crutches were compared. A force direction was more in the direction of the long humeral axis, and
In vivo
Load measurement
slightly lower forces were assumed using axillary crutches. Similar force magnitudes as those experienced
Telemetry during previously measured wheelchair weight relief tasks were expected for complete unloading. The
Crutches friction-induced moment was hypothesized to act mainly around the medio-lateral axis during the swing
Walking aid phase of the body.
Shoulder load Findings: Maximum loads of up 170% of the bodyweight and 0.8% of the bodyweight times meter were measured
Shoulder forces with large variations among the patients. Higher forces were found in most of the patients using forearm
crutches. The hypothesized predominant moment around the medio-lateral axis was only found in some pa-
tients. More often, the other two moments had larger magnitudes with the highest values in female patients.
The assumed different load direction could only be found during partial unloading.
Interpretation: In general the force magnitudes were in the range of activities of daily living. However, the num-
ber of repetitions during long-lasting crutch use could lead to shoulder problems as a long-term consequence.
The slightly lower forces with axillary crutches could be caused by loads acting directly from the crutch on the
scapula, thus bypassing the glenohumeral joint. The higher bending moments in the female patients could be a
sign of lacking muscle strength for centring the humeral head on the glenoid.
© 2012 Elsevier Ltd. All rights reserved.

1. Introduction experiments (Karduna et al., 2005). Their results varied widely.

After injuries or lower limb surgery or in cases of arthritis, patients
often use crutches to reduce loading on the legs (Kemp et al., 2008).
The loads then acting in the shoulder joint are unknown. The potential
risk of overloading the shoulder joint is demonstrated by the finding
that 51% of patients with spinal cord injury have shoulder problems
when using a wheelchair (Lee and McMahon, 2002). Crutches probably
load the shoulder joint even more than wheelchair riding because the
whole bodyweight has to be carried when the lower limbs are
completely unloaded.
In the following, the term ‘shoulder loads’ denotes the 3D contact
forces and moments acting in the gleno-humeral joint. Until now the
only way to estimate these loads was to use mathematical models,
based on motion analyses and inverse dynamics, or cadaver
⁎ Corresponding author at: Julius Wolff Institut, Charité – Universitätsmedizin
Berlin, Germany, Augustenburger Platz 1, D-13353 Berlin, Germany.
E-mail address: peter.westerhoff@charite.de (P. Westerhoff).
Based on motion data and model calculations (Anglin et al., 2000)
high forces of 170% of bodyweight (%BW) with a variation of
90%BW were calculated for cases where a cane was used. For cases
of cerebral palsy, forces of about 40%BW were determined by
Slavens et al. (2011). In another work net moments around the shoul-
der joint and mechanical power during the swing-through-gait were
determined, but no contact loads were determined (Noreau et al.,
1995). The main reason for large variations in calculations and exper-
iments are probably the unknown muscle activation patterns and the
complex external loading pattern with multiple force application
points. Analyses can additionally be falsified by non-physiological
modeling of muscle directions and unrealistic optimization criteria.
Load data from in vivo measurements can improve this situation,
either when used as a ‘gold standard’ for validating the analytical re-
sults and consequently improving the musculoskeletal models, or
when used as an additional ‘correct’ input for the calculations. For
this purpose, synchronous measurements of in vivo loads, motion
data and EMG were taken for the hip (Heller et al., 2001; Stansfield
et al., 2003) and recently, for the shoulder joint (Nikooyan et al.,

0268-0033/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.clinbiomech.2012.03.004
712 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718

2008). Because a synchronization device was not available at the time
of measurements, such simultaneous measurements were not possi-
ble in this study involving crutch walking.
First own load measurements in a patient with an instrumented
shoulder implant revealed resultant contact forces of 118%BW during
walking when the whole weight was carried by the crutches
(Bergmann et al., 2007). Several activities of daily living, measured
with the same kind of instrumented implants in 4 subjects, led to
forces of more than 100%BW and moments above 0.5%BWm
(Westerhoff et al., 2009a).
The aim of this study was to investigate in more subjects, if the use of
crutches leads to loads exceeding the normal range during daily living
and if the crutch type has an influence on the shoulder load. In rare
cases axillary crutches (ACs) can cause artery thrombosis and crutch
palsy (Stallard et al., 1978). This has led to a nearly exclusive use of fore-
arm crutches (FCs) in Europe (Dounis et al., 1980). On the other hand
ACs are the only option in cases such as additional fractures in the
hand. Several studies on the energy expenditure of different crutch
types did not find any significant differences (Fisher and Patterson,
1981; McBeath et al., 1974; Roberts and Carnes, 1990), but this does
not necessarily indicate shoulder joint loading of a similar magnitude.
We hypothesized that ACs cause lower forces compared to FC, because
the crutch force might partly bypass the glenohumeral joint and act di-
rectly from the crutch to the scapula.
In addition to the load magnitudes and time patterns, the force di-
rections were analyzed. Directions close to the humeral axis and thus
outside of the glenoid would probably indicate that a part of the force
is not acting across the joint but via soft tissue in the subacromial
space directly to the acromion. Sufficient strength and functionality
of the rotator cuff muscles and other muscles of the shoulder girdle
is necessary to pull the implant head into the glenoid, to centre it,
and to prevent the humerus from moving upwards. ACs could possi-
bly affect the function of these muscles. In this case we expected a
force acting more in the direction of the humeral axis with the AC
than with the FC.
Moments in the joint can be caused by friction or by an eccentric
transfer of the contact force. During the loading phase of the
crutches, when the body swings forwards between the crutches,
we expected a friction-dependent positive moment component MZ
around the medio-lateral axis. A superior-anterior force shift when
actively lifting the body out of the wheelchair (‘weight relief’) was
calculated (van Drongelen et al., 2006). Because this mechanical sit-
uation resembles walking on crutches without any foot-floor con-
tact, we hypothesized a force shift in the same direction, causing a
positive MX and a negative MY.
2. Methods
2.1. Instrumented implants
Clinically proven shoulder implants (BIOMODULAR, Biomet
Deutschland) were equipped with a 9-channel telemetry, 6 semi-
conductor strain gauges and an inductive power supply (Graichen
et al., 2007). These measure the 3 force and 3 moment components
acting on the implant head with an accuracy of about 2%.
The telemetry is powered by an induction coil in the implant stem.
The antenna at the tip of the stem transmits the strain signals and the
supply voltage level to an external device which regulates the power
and pre-processes the signals. All electronics inside the implant are
safely sealed by electron beam welds. Detailed information about
the implant is given elsewhere (Westerhoff et al., 2009b).
2.2. Subjects
Six subjects (3 male, 3 female; 63 to 81 years old) with osteoar-
thritis of the shoulder and functional rotator cuff participated in this
study (Table 1). Their glenoids were in good condition and therefore
not replaced. A deltoideo-pectoral approach was used. Five subjects
obtained the implant on their dominant right side while subject No.
3 received it on her non-dominant left side. The active and passive
ranges of motion are given in Table 1.
The Ethics Committee of our hospital approved implantation of
the modified implants. Before surgery, the procedure was explained
to the patients and they gave their written consent to implantation
of the modified shoulder implant, taking the measurements, and pub-
lishing their images.
2.3. Measurements
All subjects had experience in using crutches from previous surger-
ies or injuries. Nevertheless they were trained by a physiotherapist to
walk with 2 crutches in 3-point gait. Measurements were taken 6 to
18 months postoperatively on level ground in a gym at a self-selected
speed of 2–3 km/h.
2.3.1. Forearm crutches versus axillary crutches
The measurements were taken with ‘forearm crutches’ (FCs), also
named ‘elbow crutches’ or ‘French crutches’, and with ‘axillary
crutches’ (ACs), also known as ‘underarm crutches’ or ‘German
crutches’. The crutch height was adjusted by the physiotherapist.

Table 1
Subject data and average peak resultant forces.

Subject S2R S3L S4R S5R S7R S8R

Gender Male Female Female Female Male Male

Age 63 71 81 68 68 73
Weight (kg) 85 72 50 103 89 83
Implant head size (mm) 44 48 44 48 48 50
Replaced joint Right Left Right Right Right Right
Post-operative time (months) 18 16 7 17 12 6
Range of motion active (passive)
Elevation 160° (170°) 150° (160°) 110° (120°) 120° (125°) 70° (80°) 120° (130°)
Abduction 110° (120°) 130° (150°) 90° (100°) 90° (100°) 40° (50°) 120° (130°)
External rotation 30° (40°) 40° (50°) 30° (35°) 25° (35°) 20° (30°) 40° (45°)
Internal rotation 90° 90° 80° 80° 80° 90°

Average peak resultant force [%BW]

Forearm crutch “Part” 50.1* 63.2 83.0* 54.4* 67.9* 49.0
“Full” 128.0* 120.0 172.1 — 97.1* 171.0*
Axillary Crutch “Part” 26.7 66.0 54.5 44.5 58.2 48.3
“Full” 85.1 128.0* — — 80.1 108.4

“Part” = crutch partly loaded, “Full” = crutch fully loaded, leg unloaded. Asterisk = P-value b 0.05 comparing forearm and axillary crutches.
 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718 713

2.3.2. Partial load versus full load bearing
In the following the terms ‘full or partial weight bearing’ refer to
loading of the crutches and not the leg.
The subjects first walked with partial weight bearing and then
with full weight bearing, i.e. completely unloaded the in leg. Due to
insufficient muscular strength, only 4 subjects were able to walk
with full weight bearing with both crutch types for a sufficient num-
ber of load cycles.
2.4. Evaluation of data
In order to obtain more uniform load data, all loads were normal-
ized to bodyweight. Forces are stated in %BW, moments in %BWm.
Values in N or Nm can be obtained by multiplication with 1% of the
subject's body weight in N.
Separately for both crutch types and both load conditions, the
peak values of the resultant forces and moments from 10 to 15
steps of the same subject were averaged arithmetically. This delivered
‘individual’ averages. A Mann–Whitney U test using a significance
level of 0.05 was applied to test whether there are differences on a
group level. A Wilcoxon Test for connected samples was used to com-
pare the two crutch types inside each subject whether these individ-
ual averages of the same subject were significantly different for ACs
or FCs. The individual averages of all 6 subjects were then averaged
again arithmetically, and this delivered ‘typical’ averages.
Additionally the time courses of resultant forces and moments as
well as their components were averaged by mean courses, using a
time warping procedure (Bender and Bergmann, in press). This pro-
cedure also delivered the accompanying 25% and 75% percentile
courses. The averaged load cycles begin and end when the resultant
force reaches its minimum shortly before the crutch touches the
ground. The peak values of the averaged time courses can differ
slightly from the individual averages.
All data are presented in the right handed coordinate system of
the right humerus with the X-axis pointing anterior, Y-axis pointing
superior and Z-Axis in lateral direction (Wu et al., 2005). The data

Forearm Crutches Axillary Crutches

50 S2R 50 S2R

0 0
-20 -20

60 S3L 60 S3L

0 0

-60 -60

80 S4R 80 S4R

0 0

-60 -60
60 60
S5R S5R
BW]
Force [%B

0 0

-40 -40

60 S7R 60 S7R

0 0
-20 -20

50 50
S8R S8R

0 0

-30 -30
0 0.5 1.0 1.5 2.0 2.5 0 0.5 1.0 1.5 2.0 2.5
Time [s] Time [s]

Fig. 1. Forces during partial crutch loading. Resultant forces (black) and components FX (green), FY (blue) and FZ (red) for each subject using forearm crutches (FC, left) and axillary
crutches (AC, to the right). Thick lines indicate average time patterns, thin lines the 25 and 75 percentiles. Forces (different scales) in percent of body weight. Shorter curves indicate
faster movement.
714 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718

of subject S3L with the left-sided implant were mirrored to the right
side. The coordinate system origin is located in the centre of the im-
plant head.
3. Results
3.1. Partial crutch loading (Figs. 1 and 2, Table 1)
3.1.1. Forearm crutches
The peak resultant forces had individual averages between
49.0%BW (S8R)) and 83.0%BW (S7R). This is a range of 57% of the typ-
ical average of 61.3%BW. The resultant moments varied more. Their
peak values had individual averages between 0.04%BWm (S2R) and
0.47%BWm (S4R); i.e. 187% of the typical average of 0.23%BWm.
Uniform directions were measured in all subjects for the force com-
ponent FY, which always acted in the inferior direction, and for FZ in the
lateral direction. No uniform signs were found for the anterior/posterior
(a/p) component FX. None of the moment components had uniform di-
rections in all subjects, although the moment MX was always negative
in 5 of the 6 subjects. Subjects S2 and S8 with the best physical condition
had the smallest moment components. S3L showed very high moments,
as found in other studies (Bergmann et al., 2011).
3.1.2. Axillary crutches
The peak resultant forces had individual averages between
26.7%BW (S2R) and 66.0%BW (S3L). This is a range of 80% in relation
to the typical average of 49.7%BW. The individual peak resultant mo-
ment lay between 0.10 (S2R) and 0.30%BWm (S5R), a range of 105%
in relation to the typical average of 0.19%BWm. Negative moments
around the x-axis were found in all subjects. However, in S8R MX
was negative only in a short period of the load cycle.
3.1.3. Comparison of crutch types
In 5 of the 6 subjects, the averaged peak forces were lower when
using an AC than with a FC. In S2R, S4R, S5R and S7R the differences
were significant. S2R showed the largest decrease of 51%. S3L had
slightly higher loads with an AC compared to a FC. The subject specific
stride length varied widely between 1.4 s and almost 2.5 s but was
very similar in the same subject using different crutch types.

Forearm Crutches Axillary Crutches

0.1
S2R 0.1 S2R

0 0

-0.1 -0.1
0.3 S3L 0.3 S3L

0 0

-0.2 -0.2

0.5 0.5
S4R S4R

0 0
oments [%BWm]

-0.5 -0.5

0.3 S5R 0.3 S5R

Mo

0 0

-0.3 -0.3

0.2 S7R 0.2 S7R

0 0

-0.2 -0.2

S 8R S8R
0.1 0.1

0 0
0.04 0.04

0 0.5 1.0 1.5 2.0 2.5 0 0.5 1.0 1.5 2.0 2.5
Time [s] Time [s]

Fig. 2. Moments during partial crutch loading. Resultant moments (black) and components MX (green), MY (blue) and MZ (red) for each subject using forearm crutches (to the left)
and axillary crutches (to the right). Thick lines indicate average time patterns; thin lines the 25 and 75 percentiles. Moments (different scales) in percent of body weight × meter.
 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718 715

No uniform tendency was found for the interquartile force ranges
with the two crutch types (Fig. 1). S8 e.g. showed the expected higher
variation when using an AC, while S4 had smaller interquartile ranges
with an AC. The moments of S2 and S7 showed the expected higher
variation when using an AC, while S4 had lower magnitudes and
interquartile ranges with an AC.
3.2. Full crutch loading (Figs. 3 and 4, Table 1)
The force always acted in the lateral and inferior direction in all
subjects, while no trend was seen for the a/p component FX. The a/p
moment component MX was negative in all subjects but S8R, who
had negative values only during a small period of the motion cycle.
The moments in the strong male subjects S8R, S2R, and S7R were gen-
erally lower than in the female subjects. MY was negative in all sub-
jects except S2R. No clear trend was seen for MZ.

3.2.1. Forearm crutches 3.3. Axillary crutches

The individual averages of the resultant forces reached or
exceeded the bodyweight in almost all subjects. They varied between
97.1%BW (S7R) and171%BW (S8R) or 172.1%BW (S4R), which is a
variation of 53% in relation to the typical average of 129.0%BW. How-
ever, S4R was not able to walk more than 5 steps with the FC and
could not fully load the AC at all. Therefore she was not included in
calculating the typical average. The resultant moment varied between
0.21 and 0.79%BWm (Ø 0.44%BWm; variation 132%). As with partial
loading, the moment's variations between the subjects were by far
larger than the variation inside one subject. The subject specific stride
length was shorter for all subjects compared to partial crutch use.
The typical average resultant force was 100.4%BW, varying by 48%
between 80.1 and 128.0%BW. The typical resultant moment was on
the average 0.36%BWm with individual averages between 0.19 and
0.64%BWm, which is a variation of 125%.
The forces always acted in lateral-inferior directions. The moment
MX was always negative except in S8R who showed positive values in
the first part of the cycle.
Comparing both crutch types, the resultant force was smaller with
an AC than with a FC in all subjects except S3L. In four subjects these dif-
ferences were significant. S3L had non-significantly higher forces with

Forearm Crutches Axillary Crutches

100
S2R 100 S2R

0 0

-50 -50

100 S3L 100 S3L

0 0

-100 -100

150 S4R

0 NO DATA
BW]

-100
Force [%B

100 S7R 100 S7R

0 0

-40 -40

150 S8R 150

S8R

0 0

-100 -100
0 0.5 1.0 1.5 0 0.5 1.0 1.5
Time [s] Time [s]

Fig. 3. Forces during full crutch loading. Resultant forces (black) and components FX (green), FY (blue) and FZ (red) for each subject using forearm crutches (to the left) and axillary
crutches (to the right). For further information see Fig. 1.
716 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718

an AC. The individual averages of those subjects who were able to use
both crutch types, were about 22% lower with an AC than with a FC.
3.4. Force direction (Fig. 5)
During partial crutch loading (Fig. 5) the force in the frontal plane
acted more in the direction of the humeral axis direction with an AC
than with a FC. These differences in load directions were significant
in all subjects. However, during full crutch loading only two subjects
showed the same effect. S7R had almost exactly the same direction
for both crutch types and S8R showed a contradictory behaviour.
4. Discussion
As all measurements using instrumented implants, this study is
limited by the small number of subjects. Therefore an extrapolation
on a general population or the situation in a healthy joint is difficult.
However, this implant that was used without a glenoid component is
– as far as we can see – the closest one to the natural situation. These
first in vivo measurements of shoulder joint loads during crutch
walking show that the glenohumeral joint can be loaded with more
than 100%BW during full crutch loading. Taking into account that
the joint contact area is only about 6 cm², compared to 12 cm² in
the hip joint, and the higher force levels in the hip joint (Bergmann
et al., 2001) one could expect similar peak cartilage pressure in both
joints. The shoulder contact forces when walking with full crutch
loading were in the upper range of those during some activities of
daily living (Westerhoff et al., 2009a). During partial crutch loading
they were similar to those during forward flexion of the stretched
arm without any additional weight.
The force levels determined here for partial or full loading of two
crutches were in some patients similar to the value of 170%BW calculat-
ed previously (Anglin et al., 2000). However, those were calculations in-
volving just one cane. As in those calculations, there was a large variation
among the patients in our measurements. The in vivo data presented can
be used for validating and improving musculoskeletal models (Nikooyan
et al., 2010).
During previously measured activities of daily living (Westerhoff
et al., 2009a) as well as during elevating motions of the arm
(Bergmann et al., 2011) one of the subjects (S3L) always revealed

Forearm Crutches AxillaryCrutches

0.2 S2R 0.2 S2R

0 0

-0.15 -0.15

0.6 S3L 0.6 S3L

0 0

-0.4 -0.4

0.8 S4R
Moments [%BWm]

0 NO DATA

-0.6
M

0.3 S7R 0.3 S7R

0 0

-0.3 -0.3

S8R S8R
0.2 0.2

0 0

-0.2 -0.2
0 0.5 1.0 1.5 0 0.5 1.0 1.5
Time [s] Time [s]

Fig. 4. Moments during full crutch loading. Resultant moments (black) and components MX (green), MY (blue) and MZ (red) for each subject using forearm crutches (to the left) and
axillary crutches (to the right). For further information see Fig. 2.
 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718
Force direction during partial crutch loading
AC* Ø 35° AC* Ø 27°
FC Ø 43°
FC Ø 57°
S2R S3L S4R
AC* Ø 29°
AC* Ø 59°
FC Ø 46°
FC Ø 66°
S5R S7R S8R
Fig. 5. Force direction during partial and full crutch loading. Magnitude and direction of peak resultant forces F in the frontal plane. “FC” = forearm crutch = red or black lines,
“AC” = axillary crutch = green or gray lines. Average values (thick lines and numbers) and standard deviations (thin lines) from 10 to 15 trials of 6 subjects. Asterisk = significant
difference between an AC and a FC.
much higher moments than all other subjects. In the current study
this was not consistently the case. Interestingly all female subjects
(S3L, S4R, S5R) showed higher moments than the male subjects
(S2R, S7R, S8R). A possible explanation could be the better muscular
constitution of the male subjects, allowing a better centring of the hu-
merus in the glenoid cavity. S3L showed very high moments as seen
in other studies, but the differences between male and female were
not that obvious during standard motions (Bergmann et al., 2011)
or activities of daily living (Westerhoff et al., 2009a).
As a general impression, the time-load-course and the stride
length was very individual among the subjects.
Comparing both crutch types, lower forces were expected when
using ACs because the force may partly bypass the glenohumeral
joint due to contact between the scapula and crutch. This effect was
indeed seen in all investigated subjects for partial crutch loading. Al-
though the differences were statistically significant, conclusions for
the general population should be drawn very carefully, because the
investigated cohort was very inhomogeneous and the situation in
an artificial joint differs from a healthy joint. During full crutch load-
ing, 3 out of 4 subjects showed the same effect. All subjects were ex-
perienced in using FCs but not in using ACs. This could have possibly
influenced the results.
4.1. Partial crutch loading
The reproducibility of partial crutch loading measurements is limit-
ed, because load reduction of the leg was individually different, crutch
forces were not measured, and the load can be unevenly distributed be-
tween both crutches. Nevertheless, they are representative for the clin-
ical situation short time after TKR or THR, because the patients differ
considerably with regard to their strength, motivation and coordinative
abilities. These factors influence the load carried by the crutches and
717
Force direction during full crutch loading
AC* Ø 20° AC* Ø 35°
AC 35 AC* Ø 24°
FC Ø 46°
FC Ø 41°
FC Ø 44
44°
S2R S3L
AC* Ø 42° FC*Ø 41°
FC Ø 66°
FC Ø 49° AC Ø 51°
AC Ø 67°
S7R S8R
could cause large variations among the subjects. This variability also un-
derlines the finding that a reproducible reduction of leg loading by
crutches must be trained intensively (Bergmann et al., 1978). Practicing
the use of a crutch could therefore be beneficial before scheduled sur-
geries. However, it is impossible to use a crutch before to traumatic
injuries.
During partial crutch loading all subjects showed forces which
acted more in the direction of the humeral axis with ACs than with
FCs. This finding is in accordance with our initial expectations. Such
forces' directions could lead to higher loads on the soft tissue in the
subacromial space and thus possibly cause an impingement syn-
drome (Karduna et al., 2005). Therefore we would prefer FCs if their
use is not prevented by additional traumas, for example at the hand.
4.2. Full crutch loading
To improve mathematical models of shoulder biomechanics, mea-
surements during full crutch loading are better suited than they are
during partial loading. Even more advantageous would be the syn-
chronous measurement of crutch and ground reaction forces, which
could not be taken because synchronous data could not be taken
due to technical problems. Although the shoulder contact forces did
not exceed those during activities of daily living, one could expect
that the high number of repetitions during crutch walking could be
decisive for shoulder problems after long-term use of crutches.
In general the forces varied much less intra-individually than did
the moments. This effect was also seen in other studies with the
same cohort (Bergmann et al., 2011; Westerhoff et al., 2009a).
We hypothesized that the friction-induced moment MZ around
the medio-lateral axis would be positive when the body swings for-
wards, i.e. during the loading phase of the crutches. This expectation
was only met in some patients. The other hypothesis that MZ would
718 P. Westerhoff et al. / Clinical Biomechanics 27 (2012) 711–718
be much higher than both of the other moment components was only
confirmed in subject S7R. More often MY, the torque around the long
humeral axis, and MX around the a/p axis exceeded the component
MZ.
In addition to friction, moments can also be caused by an eccentric
load transfer in the joint. Such a load shift could be caused by a lack of
muscle force in the m. pectoralis major, m. latissimus dorsi and m. teres
major and the rotator cuff to centre the humeral head in the glenoid
cavity. This may possibly explain the lower moments in the stronger
male subjects.
Negative values of MX – interpreted as a superior/inferior force shift –
do not correspond to the calculations of van Drongelen et al. (2006), who
analyzed a weight relief task from a wheelchair. However, our own mea-
surements of weight relief out of a wheelchair (Peter Westerhoff et al.,
2011) showed that those assumptions of van Drongelen were only met
for the static holding position. During the motion up out of the wheel-
chair and back into it, the MX values were similar to those found here.
The negative values of MY – interpreted as a force shift in the a/p
direction – in 5 out of the 6 subjects support the calculations of van
Drongelen, indicating an anterior shift.
The force directions in the frontal plane during full crutch loading
deviated very much among individuals (Fig. 5). However, in the same
subject they did not change much throughout the loading cycles or
when trials were repeated. This can be seen by the small standard de-
viations in Fig. 6, and also in the supplementary video data provided
at www.OrthoLoad.com. Such very constant directions of high forces
were also observed in hip and knee joints (Bergmann et al., 2001)
(Kutzner et al., 2010) and seem to be a basic principle of long bone
loading in humans. At the shoulder this suggests that an intact mobil-
ity of the scapula and sufficient muscle strength is needed to keep the
force vector inside the glenoid cavity.
Acknowledgements
This project was financed by the Deutsche Forschungsge-
meinschaft (BE804/17-1) and by Synthes Inc. The non-modified orig-
inal implants were provided by Biomet Deutschland GmbH. We thank
our patients for their motivated cooperation!
Appendix A. Supplementary data
Supplementary data to this article can be found online at doi:10.
1016/j.clinbiomech.2012.03.004.
References
Anglin, C., Wyss, U.P., Pichora, D.R., 2000. Glenohumeral contact forces. Proceedings of
the Institution of Mechanical Engineers Retrieved from Pt. H J. Eng. Med. 21 (6),
637–644http://www.ncbi.nlm.nih.gov/pubmed/11201411.
Bender, A., & Bergmann, G. (in press). Determination of typical patterns from
strongly varying signals. Comput. Meth. Biomech. Biomed. Eng. doi:10.1080/
10255842.2011.560841.
Bergmann, G., Kolbel, R., Rauschenbach, N., Rohlmann, A., 1978. Walking with
canes and forearm-crutches (author's transl) Retrieved from Z. Orthop. Ihre
Grenzgeb. 116 (1), 106–113http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=654430.
Bergmann, G, Deuretzbacher, G., Heller, M., Graichen, F., Rohlmann, A., Strauss, J., &
Duda, G. N. (2001). Hip contact forces and gait patterns from routine activities. J.
Biomech., 34(7), 859–871. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/
query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11410170
Bergmann, G., Graichen, F., Bender, A., Kaab, M., Rohlmann, A., Westerhoff, P., 2007. In
vivo glenohumeral contact forces—measurements in the first patient 7 months
postoperatively Retrieved from J. Biomech. 40 (10), 2139–2149http://www.ncbi.
nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17169364.
Bergmann, G., Graichen, F., Bender, A., Rohlmann, A., Halder, A., Beier, A., Westerhoff, P.,
2011. In vivo gleno-humeral joint loads during forward flexion and abduction.
J. Biomech. 44 (8), 1543–1552. doi:10.1016/j.jbiomech.2011.02.142 Elsevier.
Dounis, E., Rose, G.K., Wilson, R.S., Steventon, R.D., 1980. A comparison of efficiency of
three types of crutches using oxygen consumption Retrieved from Rheumatol.
rehabil. 19 (4), 252–255http://www.ncbi.nlm.nih.gov/pubmed/7209290.
Fisher, S.V., Patterson, R.P., 1981. Energy cost of ambulation with crutches Retrieved
from Arch. Phys. Med. Rehabil. 62 (6), 250–256http://www.ncbi.nlm.nih.gov/
pubmed/7235917.
Graichen, F., Arnold, R., Rohlmann, A., Bergmann, G., 2007. Implantable 9-channel te-
lemetry system for in vivo load measurements with orthopedic implants Retrieved
from IEEE Trans. Biomed. Eng. 54 (2), 253–261http://www.ncbi.nlm.nih.gov/
entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17278582.
Heller, M.O., Bergmann, G., Deuretzbacher, G., Dürselen, L., Pohl, M., Claes, L., Haas, N.P.,
et al., 2001. Musculo-skeletal loading conditions at the hip during walking and
stair climbing Retrieved from J. Biomech. 34 (7), 883–893http://www.
sciencedirect.com/science/article/B6T82-437XPFY-6/2/
2efde4e14ad48dd5b0864669b830fa6e.
Karduna, A.R., Kerner, P.J., Lazarus, M.D., 2005. Contact forces in the subacromial space:
effects of scapular orientation Retrieved from J. Shoulder Elbow Surg. 14 (4),
393–399http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16015239.
Kemp, G., Crossley, K.M., Wrigley, T.V., Metcalf, B.R., Hinman, R.S., 2008. Reducing joint
loading in medial knee osteoarthritis: shoes and canes. Arthr. rheum. 59 (5),
609–614. doi:10.1002/art.23578.
Kutzner, I., Heinlein, B., Graichen, F., Bender, A., Rohlmann, A., Halder, A., Beier, A., et al.,
2010. Loading of the knee joint during activities of daily living measured in vivo in
five subjects. J. Biomech. 43 (11), 2164–2173. doi:10.1016/j.jbiomech.2010.03.046
Elsevier.
Lee, T.Q., McMahon, P.J., 2002. Shoulder biomechanics and muscle plasticity: implica-
tions in spinal cord injury Retrieved from Clin. Orthop. Relat. Res. (403 Suppl.),
S26–S36http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12394450.
McBeath, a a, Bahrke, M., Balke, B., 1974. Efficiency of assisted ambulation determined
by oxygen consumption measurement. J. Bone Joint Surg. Br. American volume, 56
(5), 994–1000 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/4847243.
Nikooyan, A.A., Veeger, H.E.J.D., van der Helm, F.C.T., Westerhoff, P., Graichen, F.,
Bergmann, G., 2008. Comparing model-predicted Gh-joint contact forces by in-
vivo measured forces. J. Biomech. 41 (S1), S145. doi:10.1016/S0021-9290(08)
70145-3.
Nikooyan, A.A., Veeger, H.E.J., Westerhoff, P., Graichen, F., Bergmann, G., van der Helm, F.C.T.,
2010. Validation of the delft shoulder and elbow model using in-vivo glenohumeral
joint contact forces 43 (15), 3007–3014. doi:10.1016/j.jbiomech.2010.06.015 Elsevier.
Noreau, L., Richards, C. L., Comeau, F., & Tardif, D. (1995). Biomechanical analysis of
swing-through gait in paraplegic and non-disabled individuals. Journal of Biome-
chanics, 28(6), 689. Retrieved from http://www.sciencedirect.com/science/
article/B6T82-42JYWR6-5/2/10f18a784a58400309d46df1bec365bc
Roberts, P., Carnes, S., 1990. The orthopaedic scooter—an energy-saving aid for assisted
ambulation. J Bone Joint Surg [Br] 72-B (4), 620–621.
Slavens, B.A., Bhagchandani, N., Wang, M., Smith, P.A., Harris, G.F., 2011. An upper extrem-
ity inverse dynamics model for pediatric Lofstrand crutch-assisted gait. J. Biomech. 44
(11), 2162–2167. doi:10.1016/j.jbiomech.2011.05.012.
Stallard, J., Sankarankutty, M., Rose, G.K., 1978. A comparison of axillary, elbow and
Canadian crutches. Rheumatology 17 (4), 237–239. doi:10.1093/rheumatology/
17.4.237.
Stansfield, B.W., Nicol, A.C., Paul, J.P., Kelly, I.G., Graichen, F., Bergmann, G., 2003. Direct
comparison of calculated hip joint contact forces with those measured using
instrumented implants. An evaluation of a three-dimensional mathematical
model of the lower limb Retrieved from J. Biomech. 36 (7), 929–936http://www.
ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12757801.
van Drongelen, S., van der Woude, L.H.V., Janssen, T.W.J., Angenot, E.L.D., Chadwick,
E.K.J., Veeger, H.E.J., 2006. Glenohumeral joint loading in tetraplegia during weight
relief lifting: a simulation study. Clin. biomech. (Bristol, Avon) 21 (2), 128–137.
doi:10.1016/j.clinbiomech.2005.09.003.
Westerhoff, P., Graichen, F., Bender, A., Halder, A., Beier, A., Rohlmann, A., Bergmann, G.,
2009a. In vivo measurement of shoulder joint loads during activities of daily living.
J. Biomech. 42 (12), 1840–1849. doi:10.1016/j.jbiomech.2009.05.035 Elsevier.
Westerhoff, P., Graichen, F., Bender, A., Rohlmann, A., Bergmann, G., 2009b. An
instrumented implant for in vivo measurement of contact forces and contact
moments in the shoulder joint. Med. Eng. Phys. 31 (2), 207–213. doi:10.1016/
j.medengphy.2008.07.011.
Westerhoff, P., Graichen, F., Bender, A., Halder, A., Beier, A., Rohlmann, A., Bergmann, G.,
2011. Measurement of shoulder joint loads during wheelchair propulsion mea-
sured in vivo. Clin. Biomech. (Bristol, Avon) 26 (10), 982–989. doi:10.1016/
j.clinbiomech.2011.05.017.
Wu, G., van der Helm, F.C., Veeger, H.E., Makhsous, M., Van Roy, P., Anglin, C., Nagels, J.,
et al., 2005. ISB recommendation on definitions of joint coordinate systems of var-
ious joints for the reporting of human joint motion—part II: shoulder, elbow, wrist
and hand. J. Biomech. 38 (5), 981–992 Retrieved from.