Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No.

6 195

A Study to Find Out Relationship Between Q-Angle, Tibial

Torsion and Leg-Heel Alignment amongst Osteoarthritis Knee
Patients – A Cross Sectional Observational Study

Chandani Raiyani1, Guddi Vaghasiya1, Ashish Kakkad2

1
Internee SPB Physiotherapy College, Surat, 2Associate Professor, SPB Physiotherapy College, Surat

Abstract
Background: Osteoarthritis (OA) is the most frequent cause of disability in the India, with the medial
compartment of the knee being most commonly affected. Osteoarthritis of knee joint is common
musculoskeletal problem now days in Indian population. It is most disabling in day to day activities of life.

Purpose: Due to Osteoarthritis of knee joint, multiple changes occur in structure in and around knee joint.
Due to these structural changes, biomechanics of knee joint is altered, which in turn leads to secondary
changes in muscles, ligaments and other soft tissues also. So, energy cost of walking increases.

Objective: Objective of this study is to correlate Q angle, tibial torsion and leg heel alignment in OA knee
patients.

Setting: Different physiotherapy centres of Surat city

Method: Co relational study was done in Surat city. Selection of OA knee patients was done as per selection
criteria. Subjects were explained about the study. Informed consent forms were signed by the patient and/or
relatives. Subjects selected by purposive sampling were assessed.

Participants: Total 63 male and female OA knee patients

Outcome measure: Q angle, Tibial torsion & Leg heel alignment

Results: Data were entered in Microsoft Excel for Microsoft Windows. Descriptive analysis and corelational
test was applied by SPSS version 20 for Microsoft Windows. Moderate positive correlation was found
between Q angle & Tibial torsion, between Tibial Torsion & Leg heel alignment, between Leg heel alignment
& Q angle.

Conclusion: These findings may suggest that Q angle, Tibial torsion & Leg heel alignment are moderate
positively correlated in OA knee joint. So any change in any of above three values may alter values of other
remaining values.

Keywords: Osteoarthrits, OA patients, Q angle, Tibial torsion & Leg heel alignment

Introduction lower extremity sites, the most common region for OA

to manifest is the medial compartment of the knee.1
Osteoarthritis (OA) is the most frequent cause of
disability in the India, with the medial compartment Osteoarthritis (OA) is defined as an idiopathic
of the knee being most commonly affected. OA is a slowly progressive degenerative joint disease affecting
condition with a multifaceted etiology that affects both the arthrodial joints mainly in elderly people.2 It is
load-bearing and non–weight-bearing joints. The risk of a chronic localized joint disease and a leading cause
developing OA substantially increases with each decade of musculoskeletal pain and disability. Osteoarthritic
after the age of 40 years. Among reported upper and process involves the whole joint including cartilage,
 196 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6

bone, ligament, muscle with changes such as joint space joint movement in late stage of the disease, loose bodies
narrowing, bony osteophytes and sclerosis.3 develop in the joint, which may cause recurrent joint
effusion, pain, swelling and locking of the joint.11
Overall prevalence of knee OA was found to be
28.7% in India with age more than 40 years.4 Andhra At the knee, alignment (i.e., the hip knee-ankle
Pradesh reported as highly prevalent (68%) and angle) is a key determinant of load distribution. The
Rajasthan as minimal prevalent (8.42%) state in India load-bearing axis is represented by a line drawn from
for Knee OA. Generally, in all studies from different mid femoral head to mid ankle. In a Varus knee, this line
regions females were reported to be more affected by passes medial to the knee and a moment arm is created,
OA knee than males.5 which increases force across the medial compartment.
In a valgus knee, the load-bearing axis passes lateral to
Osteoarthritis occurs when the cartilage that cushions the knee, and the resulting moment arm increases force
the ends of bones in your joints gradually deteriorates. across the lateral compartment. These mechanical effects
Cartilage is a firm, slippery tissue that permits nearly of alignment on load distribution make it biologically
frictionless joint motion. In osteoarthritis, the slick plausible that both varus and valgus alignment
surface of the cartilage becomes rough. Eventually, if contribute to OA progression. The position and function
the cartilage wears down completely, it may be left with of the foot and ankle affect the stresses transmitted to the
bone rubbing on bone. The most common causes of knee knee. Foot problems are frequent because the interface
OA is age (40 years and older) and gender (more in female). between body and ground is subjected to high stresses
Osteoarthritis predominantly involves the weight- and load. In weight bearing foot, subtalar motion and
bearing joints, including the knees, hips, cervical and tibial rotations are interdependent.12,13
lumbosacral spine, and feet. Other commonly affected
joints include the distal interphalangeal, proximal Q angle or patellofemoral angle is the angle between
interphalangeal, and carpometacarpal joints.6,7,8 the quadriceps muscles and the patellar tendon, it is an
important indicator of biomechanical function in the
As OA progresses, however, the level of lower extremity.12
proteoglycans eventually drops very low, causing the
cartilage to soften and lose elasticity and thereby further Tibial torsion is the measurement of angle of lateral
compromising joint surface integrity. Over time, the loss rotation of the tibia.12 It is an important morphological
of cartilage results in loss of joint space. In major weight- feature of human tibia and is defined as any twisting of
bearing joints of persons with osteoarthritis, a greater the tibia on its longitudinal axis which produces a change
loss of joint space occurs at those areas experiencing the in alignment of the planes of motion of the proximal and
highest loads.8 distal articulations.14

Individuals with knee OA experience pain, stiffness, Leg-heel alignment is measuring angle between
and decreased range of motion of the joints. These calcaneus and tibia.12 It plays an important role in
symptoms significantly limit an individual’s ability to knee OA from a biomechanical perspective owing to
rise from a chair, stand comfortably, walk, or climb stairs. rotational coupling between the rear foot and tibia.15
Ultimately, these limitations lead to a loss of functional
independence.9 Risk factors are multifactorial and Osteoarthritis of knee joint is common
include older age, female gender, obesity (particularly musculoskeletal problem now days in Indian population.
in knee OA), previous joint injury, genetics and muscle It is most disabling in day to day activities of life. Due
weakness, repetitive use of joints, bone density, joint to this, multiple changes occur in structure in and around
laxity. All play roles in the development of joint OA knee joint. Due to these structural changes, biomechanics
determination of risk factors particularly in the weight- of knee joint is altered, which in turn leads to secondary
bearing joints and their modification may reduce the risk changes in muscles, ligaments and other soft tissues also;
of OA and prevent subsequent pain and disability.3,10 So, energy cost of walking is more. Very few studies are
done to correlate different measurements like Q angle,
On examination, there is swelling due to synovial tibial torsion and leg heel alignment. So, the purpose of
thickening and/or effusion, muscle wasting and this study is to correlate Q angle, tibial torsion and leg
prominence of the articular margins due to osteophytes. heel in OA knee patients.
Movement are painful and restricted. Crepitus is felt on
 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6 197

Materials and Methodology 2) Subjective complain of knee pain with knee

flexion and extension.
• Study design: Co relational study
3) Morning stiffness ≤ 60 min.
• Source of data: Different physiotherapy clinics
in Surat city 4) Both sexes (male and female).
• Sampling technique: Purposive 5) Unilateral or Bilateral knee involvement.
• Study population: OA knee patients 6) Age ≥ 40 years.
Age - ≥40 years • Exclusion criteria16:
• Sample size: 63 OA knee patients 1) Previous knee arthroplasty, history of
congenital/adolescent knee disease.
(40 unilateral involvement, 23 bilateral
involvements) 2) Clinical signs of hip and ankle joint disease.
• Search duration : 6 months 3) Pregnancy
Patients were selected based on following inclusion 4) Knee fracture
and exclusion criteria:
5) Rheumatic disease.
• Inclusion criteria16:
• Method:
1) Knee osteoarthritis diagnosed by orthopedic
surgeon.

Q angle was measured with patient in standing medial femoral condyle on the sole of foot. The angle
position by placing lower limb at right angle to the line formed by crossing these two lines was measured.
joining to ASIS (Anterior Superior Iliac Spine). A line (Figure B)
was drawn from ASIS to base of patella. Second line
For measuring leg-heel alignment, patient was in
was drawn from tibial tuberosity to base of patella. The
standing position. A mark was placed over the midline
angle formed by crossing these two lines was measured.
of the calcaneus at the insertion of the Achilles tendon.
(Figure A)
Second mark was placed approximately 1 cm distal to
For measuring tibial torsion, patient was in prone the first mark and as close to the midline of calcaneus
position with affected knee in 90 degree flexed. A line as possible. A calcaneal line was drawn to join the two
was drawn between lateral and medial malleoli on the marks. Then tibial line was drawn to make two marks on
sole of foot. Second line was drawn between lateral and the lower third of leg in the midline. The angle formed
 198 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6

by crossing these two lines was measured. (Figure C) positive correlation was found between Q angle and
Tibial torsion; Tibial torsion and Leg heel alignment;
Data Analysis & Result Q angle and Leg heel alignment of the patients with
The present study was done to study to find out knee joint OA, which suggest that as Q angle value
relation among Q angle, Tibial torsion and Leg heel increase, Tibial torsion value increase as well as Leg
alignment in OA knee patients. The study comprised of heel alignment value also increase and vice versa.
total 63 subjects (19 males & 44 females). Data were A study by Anand Heggannavar, et.al. (2016)
entered in Microsoft Excel for Microsoft Windows. previously done indicate that the Q angle increases with
Mean + Standard Deviation values for Q angle, tibial increased tibial external rotation. There is increased load
torsion and leg heel alignment found were 27.78o + of weight bearing joint, and also changes in compensatory
4.64o, 13.5o + 4.06o and 12.86o + 3.55o respectively. 40 gait patterns like slow walking and increased toe-out
patients had unilateral osteoarthritis and 23 patients had angle.12 A study Anh D N, Michelle B C, et.al. (2009)
bilateral osteoarthritis of knee. previously done indicate that increased tibiofemoral
Pearson co-relation test was applied by SPSS version angle, which represents the valgus angle formed by the
20 for Microsoft Windows among above measurements anatomical axes of the femur and tibia, would move the
and results were found as below: patella medially relative to the anterior superior iliac
spine and the tibial tuberosity laterally thus increasing
Table 1: Correlation Test between Q angle and the Q angle. When femoral anteversion is excessive, it
Tibial torsion may lead to more medial rotation of femur leading to
displacement of patella medially. Femoral anteversion
Pearson Correlation .150 may be related to in toeing gait which is compensated
with external rotation of tibia on femur causing tibial
Sig. (2-tailed) .191 tuberosity to displace more laterally.17

A study by Anand Heggannavar, et.al. (2016)

N 78
previously done indicate that the torsion is transmitted
to hind foot and ankle joint. Increased anterior pelvic
Table 2: Correlation Test between Tibial torsion tilt and navicular drop result in rotational changes in the
and Leg heel alignment femur and tibia displacing the patella medially and the
tibial tuberosity laterally. Increased medial joint loading,
Pearson Correlation .048 is evidenced by a greater knee-joint adduction moment,
has also been frequently noted in individuals with OA.12
Sig. (2-tailed) .675
A study by Nüesch C, Barg A, et.al. (2013) previously
N 78
done indicate that the asymmetric alignment of the ankle
joint leads to changes in the intra-articular pressure
Table 3: Correlation Test between Q angle and
distribution and the contact area. A varus alignment of
Leg heel alignment
the hind foot leads a shift of the pressure in anteromedial
direction and a reduction of the contact area. For a valgus
Pearson Correlation .211 alignment a pressure shift in posterolateral direction and a
reduced contact area. However, in the specimens with an
Sig. (2-tailed) .064 intact fibula and ankle joint, opposite changes were seen:
varus lead to posterolateral pressure shifts and increased
N 78 contact areas, while valgus lead to anteromedial pressure
shifts and decreased contact areas.18

Discussion Holister et. Al. (2011) suggested that in the externally

rotated knee the coupled rotation of the femur and tibia
Purpose of the present study was to find out
in the screw home mechanism may be reversed. With
the relation among Q angle, Tibial torsion and Leg
the knee externally rotated, the bony attachments for the
heel alignment in OA knee patients. In study, moderate
 Indian Journal of Public Health Research & Development, June 2020, Vol. 11, No. 6 199

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