Background: This study was designed as an investigation in a local population to assess the relation between the knee joint and spinal alignment in a population-based study using the SpinalMouse.
Methods: Medical check-ups were conducted for residents of a mountain village in Japan. The study population included 107 men and 157 women (528 knees) with a mean age of 71.1 ± 6.8 years (range, 60–87 years). A questionnaire dealing with any current symptoms involving the knees was administered, and physical examinations dealing with the range of motion (ROM) of knee were conducted. The SpinalMouse was used to measure sagittal spinal alignment and spinal ROM. The parameters considered were thoracic kyphosis angle, lumbar lordosis angle (LLA), sacral inclination angle (SIA), and trunk angle of inclination (INC). The patients were divided into a group with knee flexion contracture (FC group) and a group without knee FC (non-FC group) to conduct a comparative study of both groups.
Results: With regard to static spinal alignment, LLA and SIA decreased significantly in the FC group (p < 0.05). With regard to spinal ROM, LLA and INC decreased significantly in the FC group (p < 0.05).
Conclusion: Results suggested that the knee and the spine affect each other and that the spinal ROM is also involved. The current study may explain the development of knee-spine syndrome

Atsushi Yamamoto

Kenichi Saito

Kenji Takagishi

Masaki Shimizu

Naoki Sato

Shinya Yanagisawa

Asia-Pacific Journal of Sports Medicine Arthroscopy Rehabilitation and Technology

AbstractBackgroundThis study was designed as an investigation in a local population to assess the relation between the knee joint and spinal alignment in a population-based study using the SpinalMouse.MethodsMedical check-ups were conducted for residents of a mountain village in Japan. The study population included 107 men and 157 women (528 knees) with a mean age of 71.1 ± 6.8 years (range, 60–87 years). A questionnaire dealing with any current symptoms involving the knees was administered, and physical examinations dealing with the range of motion (ROM) of knee were conducted. The SpinalMouse was used to measure sagittal spinal alignment and spinal ROM. The parameters considered were thoracic kyphosis angle, lumbar lordosis angle (LLA), sacral inclination angle (SIA), and trunk angle of inclination (INC). The patients were divided into a group with knee flexion contracture (FC group) and a group without knee FC (non-FC group) to conduct a comparative study of both groups.ResultsWith regard to static spinal alignment, LLA and SIA decreased significantly in the FC group (p < 0.05). With regard to spinal ROM, LLA and INC decreased significantly in the FC group (p < 0.05).ConclusionResults suggested that the knee and the spine affect each other and that the spinal ROM is also involved. The current study may explain the development of knee-spine syndrome

Yanagisawa, Shinya

Sato, Naoki

Shimizu, Masaki

Saito, Kenichi

Yamamoto, Atsushi

Takagishi, Kenji

Elsevier - Publisher Connector 

Available online at www.sciencedirect.comScienceDirect
Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 68e71
www.ap-smart.comOriginal article
Relation among the knee, sagittal spinal alignment, and the spinal
range of motion: Investigation in local medical check-ups using
the SpinalMouse
Shinya Yanagisawa a,*, Naoki Sato b, Masaki Shimizu c, Kenichi Saito a,
Atsushi Yamamoto a, Kenji Takagishi a
a Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
b Department of Orthopaedic Surgery, Isesaki Municipal Hospital, Isesaki, Gunma, Japan
c Keiyu Orthopaedic Hospital, Tatebayashi, Gunma, Japan
Received 18 August 2014; revised 9 January 2015; accepted 22 January 2015
Available online 7 March 2015AbstractBackground: This study was designed as an investigation in a local population to assess the relation between the knee joint and spinal alignment
in a population-based study using the SpinalMouse.
Methods: Medical check-ups were conducted for residents of a mountain village in Japan. The study population included 107 men and 157
women (528 knees) with a mean age of 71.1 ± 6.8 years (range, 60e87 years). A questionnaire dealing with any current symptoms involving the
knees was administered, and physical examinations dealing with the range of motion (ROM) of knee were conducted. The SpinalMouse was
used to measure sagittal spinal alignment and spinal ROM. The parameters considered were thoracic kyphosis angle, lumbar lordosis angle
(LLA), sacral inclination angle (SIA), and trunk angle of inclination (INC). The patients were divided into a group with knee flexion contracture
(FC group) and a group without knee FC (non-FC group) to conduct a comparative study of both groups.
Results: With regard to static spinal alignment, LLA and SIA decreased significantly in the FC group ( p < 0.05). With regard to spinal ROM,
LLA and INC decreased significantly in the FC group ( p < 0.05).
Conclusion: Results suggested that the knee and the spine affect each other and that the spinal ROM is also involved. The current study may
explain the development of knee-spine syndrome.
Copyright © 2015, Asia Pacific Knee, Arthroscopy and Sports Medicine Society. Published by Elsevier (Singapore) Pte Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: knee; sagittal spinal alignment; SpinalMouse; spinal range of motionIntroduction
Knee osteoarthritis often causes flexion contractures (FC),
which affect the ability to perform daily activities.1 Tsuji et al2
reported a correlation between the spinal alignment and the* Corresponding author. Department of Orthopaedic Surgery, Gunma
University Graduate School of Medicine, Number 3-39-22, Showa-machi,
Maebashi, Gunma 371-8511, Japan.
E-mail address: yanashin87@yahoo.co.jp (S. Yanagisawa).
http://dx.doi.org/10.1016/j.asmart.2015.01.002
2214-6873/Copyright © 2015, Asia Pacific Knee, Arthroscopy and Sports Medicin
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nknee joint, which they called kneeespine syndrome; however,
the pathogenesis has not been clarified. In addition, previous
studies have examined outpatients or simulated knee FCs, and
little has been reported on the relationship between the knee
and the spine. Moreover, few reports have described the
relationship between the knee joint and spinal alignment as
ascertained from a population-based study.
This study was designed as a population-based study using
the SpinalMouse to assess the relationship between the knee
joint and spinal alignment in a local population. Our hypoth-
esis is that the knee and the spine affect each other and that thee Society. Published by Elsevier (Singapore) Pte Ltd. This is an open access
c-nd/4.0/).
69S. Yanagisawa et al. / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 68e71spinal range of motion (ROM) is involved in the pathogenesis
of knee osteoarthritis.
Materials and methods
This cross-sectional study was approved by the institutional
Review Board of our institution. All patients, prior to giving
their consent to participate in this study, were informed that
their data would be published. To help prevent lifestyle-related
diseases and aid the early detection of cancer, medical check-
ups were conducted in Japan for residents of a mountain
village, where agroforestry and tourism are the main industries.
A statistical power analysis based on the median effective dose
indicated an optimal sample size as > 100 patients, with a
significance level of 5% and statistical power of 0.95. The study
included 107men and 157 women (528 knees), with a mean age
of 71.1 ± 6.8 years (range, 60e87 years).
A questionnaire was administered regarding the patients' age
and sex. We also conducted physical examinations to determine
the ROM of the knees in the supine position using a goniometer.
The goniometer axis was set on the lateral epicondyle of the
femur, while the proximal arm was set parallel to the long axis of
the femur and the distal armwas set parallel to the long axis of the
fibula and pointing at the lateral malleolus. We used the Spi-
nalMouse (Idiag AG, Volketswil, Switzerland), an electronic
computer-aided measuring device, to measure the sagittal spinal
ROMand intersegmental angles noninvasively, according to a so-
called surface-based technique, to determine the sagittal spinal
alignment and ROM (Fig. 1).3,4 The device was connected to a
standard personal computer via an analogue-to-digital converter.
The SpinalMouse was placed manually on the patient's skin
surface and moved paravertebrally along the patient's spinal
column from C7 to S3, while adhering to the body surface of the
patient. The device was moved gently to prevent erroneousFig. 1. An electronic computer-aided measuring device was used to measure the sag
used with a surface-based technique to measure the sagittal spinal alignment andmeasurements. The system recorded the outline of the skin sur-
face over the sagittal spinal column. The patient was asked to take
three consecutive positions: erect, maximal flexion, andmaximal
extension of the spine. One measurement was taken in each
position. The relevant parameters recorded in each position were
as follows: all individual motion segment angles (T1/2eL5/S1),
thoracic kyphosis angle (TKA; T1/2eT11/12), lumbar lordosis
angle (LLA; T12/L1 to the sacrum), sacral inclination angle
(SIA), and trunk angle of inclination (INC; angle subtended be-
tween the vertical and a line joining C7 to the sacrum). The
intraclass coefficients for the curvature measurements obtained
using the SpinalMouse were calculated to be 0.92e0.95.3,4 To
conduct a comparative study of two groups, the patients were
divided into a group with knee FCs of knee extension loss > 5
(FC group) and a group without knee FCs (non-FC group). The
differences between the two groups in terms of age, sex, ROM of
the knee, TKA, LLA, SIA, and INCwere compared usingWelch
t test and the Chi-square test. All statistical analyses were con-
ducted using SPSS version 19.0 (SPSS Inc., Chicago, IL, USA).
Significance was inferred for p < 0.05.
Results
The FC group included 229 knees, and the non-FC group
included 299 knees. Significant differences were found be-
tween the two groups for age (72.2 ± 6.2 years in the FC
group; 70.2 ± 7.0 years in the non-FC group, p < 0.01), but not
for sex (males accounted for 39.3% of the patients in the FC
group and 41.8% of the patients in the non-FC group,
p ¼ 0.272; Table 1). The degree of knee flexion was signifi-
cantly lower in the FC group (142.3 ± 6.9 in the FC group and
139.4 ± 9.5 in the non-FC group). With regard to static spinal
alignment, the results for the FC group were TKA
37.6 ± 15.6, LLA e18.9 ± 12.3, SIA 10.7 ± 7.5, and INCittal spinal range of motion (ROM) noninvasively. Intersegmental angles were
ROM.
Table 1
Relation between the FC group and the non-FC group.
FC group (n ¼ 229) Non-FC group (n ¼ 299) p
Age (y) 72.2 ± 6.2 70.2 ± 7.0 0.010
Sex (male:female) 90:139 124:175 0.272
Knee flexion () 139.4 ± 9.5 142.3 ± 6.9 < 0.001
FC ¼ flexion contracture.
70 S. Yanagisawa et al. / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 68e714.2 ± 5.3, whereas the results for the non-FC group were
TKA 37.2 ± 13.7, LLA e20.9 ± 11.0, SIA 12.1 ± 7.6, and
INC 3.6 ± 4.2. The results showed that the LLA and SIA
values were significantly lower in the FC group ( p < 0.05;
Table 2). Regarding spinal ROM, the results for the FC group
were TKA 47.4 ± 18.0, LLA 21.0 ± 14.1, SIA 53.1 ± 17.1,
and INC 83.5 ± 17.1, whereas the results for the non-FC
group were TKA 22.5 ± 17.8, LLA 51.0 ± 16.8, SIA
55.9 ± 23.6, and INC 105.9 ± 24.7, indicating a significant
decrease in the LLA and INC values in the FC group
( p < 0.05; Table 3).
Discussion
The most important findings of this population-based study
are that the knee and the spine affect each other and the spinal
ROM. This is the first report of a population-based investigation
of the relationship between the knee joint and spinal alignment.
Japanese society is aging rapidly, and the incidence of
Japanese patients with joint disorders is increasing.5 Therefore,
elucidating risk factors affecting the incidence and progression
of joint disorders is important to prevent such disorders.
Degenerative changes of the knee often cause FCs, and Off-
ierski and MacNab6 reported that symptomatic diseases of both
the hip and spine may produce a complex hip-spine syndrome.
However, the standing posture alignment depends not only on
the spine, but also on the hip and knee joints. Murata et al7
reported that lordosis is significantly less common in patients
with a knee extension limitation greater than 5. Harato et al8Table 2
Sagittal spinal alignment.
Parameter () FC group
(n ¼ 229)
Non-FC group
(n ¼ 299)
p
Thoracic kyphosis angle 37.6 ± 15.6 37.2 ± 13.7 0.262
Lumbar lordosis angle e18.9 ± 12.3 e20.9 ± 11.0 0.018
Sacral inclination angle 10.7 ± 7.5 12.1 ± 7.6 0.036
Trunk angle of inclination 4.2 ± 5.3 3.6 ± 4.2 0.072
FC ¼ flexion contracture.
Table 3
Spinal range of motion.
Parameter () FC group
(n ¼ 229)
Non-FC group
(n ¼ 299)
p
Thoracic kyphosis angle 47.4 ± 18.0 22.5 ± 17.8 < 0.001
Lumbar lordosis angle 21.0 ± 14.1 51.0 ± 16.8 < 0.001
Sacral inclination angle 53.1 ± 17.1 55.9 ± 23.6 0.121
Trunk angle of inclination 83.5 ± 17.1 105.9 ± 24.7 < 0.001
FC ¼ flexion contracture.reported that knee FCs significantly influence the three-
dimensional trunk kinematics during relaxed standing and
level walking. They inferred that the dynamic changes in trunk
motion observed during walking engender changes in the spinal
alignment, which may contribute to the development of spinal
deformities. These observations may explain the onset of
“knee-spine syndrome”. In these studies, knee extension limi-
tation was related to a decrease in lumbar lordosis on sagittal
plane radiographs or a gait analysis system, and few reports
have described the relationship between the knee and spine
using the SpinalMouse. Furthermore, previous studies have
examined outpatients or simulated knee FCs, and little has been
reported regarding the relationship between the knee and spine.
Based on the current findings, lumbar lordosis was significantly
less prevalent in the FC group, which confirmed the relation-
ship between FCs and spinal alignment in this population-based
study.
The SpinalMouse is available for the noninvasive assess-
ment of spinal alignment and movement.3,4,9,10 The Spi-
nalMouse makes contact with the patient's body surface and is
then moved gently to prevent erroneous measurements. The
intraclass coefficients for the curvature measurements ob-
tained with the SpinalMouse have been reported to be 0.92-
0.95.3,4 In addition, previous studies have demonstrated that
the thoracic and lumbar kyphosis angles and spinal ROMs
measured using the SpinalMouse strongly correlate with those
measured using spinal radiographs.11 Imagama et al12 reported
that SpinalMouse data showed a significant correlation with
radiological measurements in their population-based study.
Because of cost considerations and the limited time allotted
for this population-based study, we used the SpinalMouse to
examine the patients quickly. Obtaining spinal ROM mea-
surements is also possible using the SpinalMouse. However,
there are no reports in the relevant literature describing the
relationship between the knee joint and the spinal ROM.
Takemitsu et al13 reported that standing sagittal spinal mala-
lignment results from decreasing trunk muscular strength and
spinal ROM with age and that the amplitude of the quadriceps
and biceps muscles of the thigh is high, as ascertained using
electroneuromyography. The authors postulated that patients
showing sacrum dorsal tilting stand in a knee flexion position
to gain a mechanical advantage, which increases the tension of
the lower muscles. They also speculated that this tendency
influences the knee joint. Tsuji et al2 reported that changing
the spinal alignment causes patients to assume the knee flexion
position, which subsequently increases tension in the thigh
muscles. Furthermore, tight hamstrings are known to occur in
patients with knee FCs. A tight hamstring decreases spinal
flexibility.14 The results of this study demonstrate that the knee
joint, spine, and spine ROM mutually interact with each other.
Regarding TKA, flexibility was increased in the FC group,
suggesting a mechanism compensating for the loss of lumbar
spine flexibility. As to the onset of knee-spine syndrome, the
possible participation of a decrease in spinal ROM can be
inferred from these results.
This study is associated with several limitations. First, this
was a large-scale population-based study, although the
71S. Yanagisawa et al. / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 2 (2015) 68e71baseline data were cross sectional. Therefore, it is necessary to
continue research in this area to confirm the changes in
alignment using a longitudinal design. Second, the FC group
was markedly larger than the non-FC group. For this reason,
there may have been an influence of age on the results. Third,
it remains unclear whether lumbar spine or knee deformities
are the primary factor for this condition. We will continue to
investigate this point.
To summarize, the knee and spine affect each other. The
spinal ROM is also affected in patients with disorders of the
knee joint. These results suggest that the involvement of spinal
ROM decreases lumbar lordosis and sacral inclination during
knee FCs. The current observations may explain the devel-
opment of kneeespine syndrome.
Conflicts of interest
All contributing authors declare no conflicts of interest
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Relation among the knee, sagittal spinal alignment, and the spinal range of motion: Investigation in local medical check-ups using the SpinalMouse 

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