Predicting gait adaptations due to ankle plantarflexor muscle weakness and contracture using physics-based musculoskeletal simulations

Deficits in the ankle plantarflexor muscles, such as weakness and contracture, occur commonly in conditions such as cerebral palsy, stroke, muscular dystrophy, and Charcot-Marie-Tooth disease. While these deficits likely contribute to observed gait pathologies, elucidating cause-effect relationships is difficult due to the often co-occurring biomechanical and neural deficits. To elucidate the effects of weakness and contracture, we systematically introduced isolated deficits into a musculoskeletal model and generated simulations of walking to predict gait adaptations due to these deficits. We developed a planar model containing 9 degrees of freedom and 18 musculotendon actuators, and an optimization framework through which we imposed simple objectives, such as minimizing cost of transport while avoiding falling and injury, and maintaining head stability. We first validated that our model could generate gaits that reproduced experimentally observed kinematic, kinetic, and metabolic trends for two cases: 1) walking at prescribed speeds between 0.50 m/s and 2.00 m/s and 2) walking at self-selected speed. We then applied mild, moderate, and severe levels of muscle weakness or contracture to either the soleus (SOL) or gastrocnemius (GAS) or both of these major plantarflexors (PF) and retrained the model to walk at a self-selected speed. The model was robust to all deficits, finding a stable gait in all cases. Severe PF weakness caused the model to adopt a slower, "heel-walking" gait. Severe contracture of only SOL or both PF yielded similar results: the model adopted a "toe-walking" gait with excessive hip and knee flexion during stance. These results highlight how plantarflexor weakness and contracture may contribute to observed gait patterns. Our model, simulation and optimization framework, and results are freely shared so that others can reproduce and build upon our work. Author summary Deficits in the muscles that extend the ankle are thought to contribute to abnormal walking patterns in conditions such as cerebral palsy, stroke, muscular dystrophy, and Charcot-Marie-Tooth disease. To study how deficits in these muscles contribute to abnormal walking patterns, we used computer simulations to systematically introduce muscle deficits into a biomechanically accurate model. We first showed that our model could discover realistic walking patterns over a wide range of speeds when we posed a simple objective: walking while consuming a minimum amount of energy per distance, maintaining head stability, and avoiding injury. We then used the model to study the effect of two commonly observed problems: muscle weakness and muscle tightness. We found that severe weakness of the ankle extensors caused the model to adopt a slower, “heel-walking” gait, and severe tightness caused the model to adopt a crouched, “toe-walking” gait. These results highlight how deficits in the ankle extensor muscles may contribute to abnormal walking patterns commonly seen in pathological populations.