**4.1 Knee joint**

*Proprioception*

logical examination.

Joint sense and vibration sense examination is an important component of neuro-

(especially involving large fibers), dorsal root ganglionopathies and subacute combined degeneration. With parietal lobe lesion, position sense is often impaired and vibration preserved [5]. Vibratory sensation may also be impaired in lesions of the peripheral nerves, plexopathies, radiculopathies, dorsal root ganglion, posterior columns and medial lemniscus. In patients with peripheral neuropathies, vibration sensation is lost in the lower extremities first. Impaired vibration from posterior column disease is more likely to be uniform at all sites in the involved extremities. In spinal cord diseases, detecting a "level" of vibration sensory (segmental demarcation) loss over the spinous processes is crucial for diagnosis [5]. In patients with diabetic neuropathy, the decline in proprioceptive function may be caused by impairment in muscle spindle function and or the spindle receptors itself [47].

The classic diseases causing sensory ataxia are tabes dorsalis, polyneuropathies

In patients with hereditary sensory and autonomic neuropathy type III patients

Neglect is a condition in which patients loose self-spatial awareness opposite to the damaged site of the brain. It is proposed that it is associated with the lesions of the dorsal stream causing dysfunction of proprioceptive space which is encoded in the bilateral parietal cortex [53]. Loss in the position sense may cause pseudochoreoathetosis as well. This abnormal involuntary, spontaneous movements are restricted to the parts with proprioceptive sensory loss. It is proposed that failure to integrate cortical proprioceptive sensory inputs in striatum may explain this

There are experimental evidence of proprioception impairments in Parkinson's disease. Parkinsonian gait is affected by the involvement of lower limb proprioceptive deficits as well as the involvement contralateral somatosensory and premotor lateral cortices and posterior cingulate cortex and basal ganglia and bilateral prefrontal cortex [10, 55, 56]. It was also shown that conscious perception of kinaesthetic stimuli is impaired in Parkinson's disease as cerebro-basal loops are not

Weeks and colleagues showed that patients with cerebellar damage had reduced dynamic proprioceptive acuity which was also parallel to their motor deficits [3]. Diseases of the primary somatosensory cortex do not generally produce sensory symptoms but deteriorate fine and delicate manipulations in the contralateral part depending on position sense [2, 5]. Many patients with stroke

(Riley-Day Syndrome, familial dysautonomia) ataxic gait is explained by poor proprioceptive acuity at the knee joint [48]. In mitochondrial ataxias sensory ataxia (which classically include gait ataxia worsened by loss of visual fixation) is due to the involvement of proprioception, secondary to peripheral neuropathy or neuronopathy [49]. In patients following whiplash type injuries involving soft tissues of cervical spine leads to proprioceptive deficits affecting head and position sense. Also in patients with chronic whiplash associated disorders are reported to have balance and dizziness problems, head and eye movement impairments reflecting mismatch od afferent input from the proprioceptive, visual and vestibular systems [8, 50]. Lesions of the dorsal columns impairs sensation of touch, vibration and proprioception in the ipsilateral side of the body below the injury level [51]. In patients with non-specific low back pain, postural control is impaired during standing and slow performance movements. This is due to an altered use of ankle compared to back proprioception related activity in right primary motor cortex and frontoparietal cortex [52]. Brainstem lesions resemble those in spinal cord disease as it selectively involves spinothalamic tract or medial lemniscus causing contralateral

loss of position sense and vibration sense [5].

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situation [5, 54].

intact [9].

Knee proprioception is necessary to achieve normal joint coordination during movement as well as providing joint stabilization [61, 62]. The anterior cruciate ligament (ACL), posterior cruciate ligament, collateral ligaments and menisci contribute to proprioception with the help of proprioceptors they have [63, 64]. The mechanoreceptors of the cruciate ligaments, together with the mechanoreceptors of the joint capsule, transmit information about the extension and flexion of the knee joint to the brain [65].

The ACL is the most important ligament involved in knee mechanical and neuromuscular stability. It contributes to proprioception in joint movement. However, the ACL is the most frequently injured ligament. After ACL rupture, knee proprioception is disrupted [66, 67].

Various autografts and allografts are used for ACL reconstruction. Patellar tendon or hamstring tendons may be preferred in patients using autografts. In addition, different techniques and materials are used. However, there is no gold standard in graft and technique selection [68]. In order for ACL reconstruction to be successful, not only mechanical but also neuromuscular stability is required. Neuromuscular stability depends on obtaining proprioception [69]. ACL injury leads to degradation of mechanoreceptors and a histologic study revealed that free nerve endings disappear after 1 year [70]. The effectiveness of ACL reconstruction in regaining proprioception has been tried to be revealed by some studies [71–74]. While some studies argue that ACL reconstruction is not sufficient to restore joint position [71–73], some studies advocate the adverse opinion [74]. The lack of a test to distinguish about whether the proprioception is derived from the soft tissues around the knee and capsule or from mechanoreceptors on ACL prevents to reach a certain decision about the mechanoreceptors of ACL [75].

Even after total knee arthroplasty, the contribution of the soft tissues around the knee to proprioception continues. In order to take advantage of this effect and ensure satisfactory outcomes in these patients, the soft tissue and gap must be well adjusted. Unicompartmental replacement protecting the ACL may be more advantageous in not reducing proprioception due to the proprioceptive effect of ACL. Also Ishii et al. [76] conclude that balance is improved after the postoperative period in bilateral total knee arthroplasty. It is stated that the first 6-week period is the critical period for adaptation time and proprioceptive loss after total knee replacement, and a new pattern in the knee load distribution occurs with postoperative rehabilitation [77].

#### **4.2 Hip joint**

Loss of proprioception, balance, sensation as joint position and kinesthetic are frequently observed in patients with knee osteoarthritis [78, 79]. Shakoor et al. [80] described significant sensory deficits associated with hip osteoarthritis, and these deficiencies involved both upper and lower limbs. The mechanism for this remains unclear; however, it has been suggested that there may be neurological feedback mechanisms or a inherent generalized neurological defect [78].

The greatest portion of mechanoreceptors and free nerve endings and highest concentration of pain receptors are located in the anterosuperior, posterosuperior and anterolateral labrum, respectively [81, 82].

There is no satisfactory information about proprioception impairment after surgeries due to hip pathologies. In the literature on the relationship between arthroplasty and proprioception, there are studies related to the knee rather than the hip. Interestingly, Ishii et al. [83] found no difference in proprioceptive responses among participants in the total hip arthroplasty, hemiarthroplasty and healthy control groups. They thought that the mechanoreceptors in the muscles, tendons and ligaments were responsible for joint proprioception rather than the intracapsular structures. While capsular receptors play a secondary role, muscle receptors play a primary role in hip proprioception. Therefore, it has been suggested that proprioception does not decrease after surgery, despite the capsule being removed during arthroplasty [84].

The effects of FAI and labral tear treatments on proprioception are not well known, but due to their proprioceptive properties, hip musculotendinous and capsuloligamentous tissues contribute to lower limb posture and stabilization through neuromuscular control. Therefore, preserving proprioceptive tissues as much as possible will prevent lower extremity injuries in arthroscopy operations.

#### **4.3 Ankle joint**

Ankle injuries are in the first place in sports-related injuries and lateral ankle sprains constitute the majority of this [85]. Unfortunately, many of these acute injuries can become chronic [86, 87]. Training, fatigue, and ankle injuries can affect ankle proprioception. Joint position sense, peroneal reaction time, EMG evaluation of peroneal muscles, and balance tests are tools to evaluate proprioception before and after ankle injuries or surgeries.

There are two important anatomical structures that provide proprioception and are located around the foot and ankle. Superior and inferior extensor retinaculum act as a pulley protecting tendons close to bony structures. The lateral ankle complex is the other anatomical structure with proprioceptive properties [88, 89]. Both acute and chronic injuries of the ankle can predispose the proprioceptors of the ankle. The differentiation in proprioception after these injuries were presented in the literature. While Vries et al. [90] stated that there was no difference between chronic ankle injury, acute trauma and healthy control groups, there are studies suggested that proprioception after acute inversion injuries and chronic ankle injuries are decreased [91–93]. Recovery of the proprioception is crucial after ankle injuries to maintain balance control. In order to achieve this, rehabilitation should not be neglected, especially after lateral ankle sprains.

A study conducted by Conti et al. [94] found no difference in proprioception between operated and non-operated side in total ankle arthroplasty. However, ankle arthroplasty has the worst outcome in terms of proprioception and balance compared to total hip and knee arthroplasty [95].

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*Proprioception and Clinical Correlation DOI: http://dx.doi.org/10.5772/intechopen.95866*

Some studies have revealed Pacinian corpuscles and Golgi tendon organ with mechanoreceptors in the shoulder [96, 97]. However, they discovered that while there are free nerve endings in the labrum and subacromial bursa, these structures do not contain mechanoreceptors. It is also thought that the supraspinatus muscle

The pathological conditions of the shoulder joint can affect shoulder proprioception. Surgical shoulder diseases include rotator cuff tears, subcacromial pathologies, biceps tendon diseases and instabilities. Studies comparing pre- and post-surgical proprioception in the shoulder joint are not sufficient. In a study conducted by Aydın et al. [99], it was revealed that there was no difference in terms of proprioception between surgically treated and non-surgically treated shoulders in cases of instability. Duzgun et al. [100] stated a rapid recovery in shoulder joint

Shoulder arthroplasty is thought to negatively affect proprioception. It has been stated that intervention to the subscapularis muscle and glenohumeral ligaments during shoulder arthroplasty may be effective in this decrease in

Soft tissue damage is significant in elbow arthroplasty. Both flexor and extensor muscles are affected, collateral ligaments are released and capsule is removed. Therefore, the proprioceptive tissues as like skin, capsule, muscle and tendons are damaged. Despite the role of proprioception is still not well-established, one study was found an impairment in proprioception after total elbow arthroplasty [103]. In conclusion, proprioception may be adversely affected after joint surgeries. It should definitely be included in the rehabilitation program considering this situation. Proprioception seems to be an important factor for gaining balance and gait

has more receptors than the infraspinatus muscle contains [98].

proprioception after rotator cuff surgery as their experience.

speed, especially after arthroplasties in the lower extremity.

The authors declare no conflict of interest.

**4.4 Shoulder joint**

proprioception [101, 102].

**4.5 Elbow joint**

**Conflict of interest**
