Clinical Biomechanics 17 (2002) 705712

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Eect of hamstrings muscle action on stability of the

ACL-decient knee in isokinetic extension exercise
Takashi Yanagawa a, Kevin Shelburne a,*
, Frank Serpas b, Marcus Pandy b

a
Steadman-Hawkins Sports Medicine Foundation, Vail, CO 81657, USA
b
Department of Biomedical Engineering, University of Texas, Austin, TX 78712, USA
Received 8 November 2001; accepted 1 August 2002

Abstract
Objective. To quantify the eect of hamstrings muscle action on stability of the anterior cruciate ligament decient knee during
isokinetic exercise at various speeds.
Design. Mathematical modeling and forward-dynamics computer simulation were used to study the interactions between knee-
extension speed, hamstrings co-contraction activity, and anterior tibial translation in the intact and anterior cruciate decient knee.
Background. There is much experimental evidence available to believe that hamstrings co-contraction can reduce anterior tibial
translation in the anterior cruciate decient knee. Little is known, however, about the level of hamstrings activation needed to keep
anterior tibial translation within normal limits during functional activity.
Methods. Isokinetic knee-extension was simulated with a sagittal-plane model used previously to study load sharing between the
muscles, ligaments, and bones during isometric knee-extension exercise, isokinetic exercise, and squatting exercise.
Conclusions. Some amount of hamstrings activation is needed to stabilize an anterior cruciate decient knee irrespective of how
fast the knee extends. The level of hamstrings co-contraction needed to stabilize an anterior cruciate decient knee is inversely
related to extension speed. Hamstrings co-contraction is more eective in reducing anterior tibial translation than low-resistance
extension exercise.

Relevance
Excessive anterior tibial translation during knee-extension exercise may lead to damage of the meniscus and other passive
structures inside the knee. If anterior cruciate decient patients can be trained to co-contract their hamstrings during isokinetic knee-
extension, then this exercise is appropriate for maintaining strength of the thigh muscles without compromising the anterior stability
of the knee.
2002 Elsevier Science Ltd. All rights reserved.

Keywords: Hamstrings co-contraction; Knee modeling; Rehabilitation exercise

1. Introduction quadriceps muscle strength [14]. Even though weight-

The primary function of the anterior cruciate liga-
ment (ACL) is to limit anterior translation of the tibia
relative to the femur. Injury to the ACL often results in
loss of thigh muscle strength, so much so that open-
chain (i.e., knee-extension) and closed-chain (i.e., weight
bearing) exercises are routinely prescribed to maintain
*
Corresponding author. Address: 181 West Meadow Drive, Suite
1000, Vail, CO 81657, USA.
E-mail address: kevin.shelburne@shsmf.org (K. Shelburne).
0268-0033/02/$ - see front matter 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 6 8 - 0 0 3 3 ( 0 2 ) 0 0 1 0 4 - 3
bearing exercises are emphasized in most ACL rehabil-
itation protocols, isokinetic knee-extension exercise is
still commonly used in the eight weeks to six months
post-injury and post-operative periods [14]. Unfortu-
nately, knee-extension exercise causes relatively large
forces to be transmitted to the ACL in the intact knee,
and yields much larger-than-normal anterior tibial
translation (ATT) when the ACL is absent [57]. Some
studies have found that the risk of injury to passive
structures such as the menisci, which provide secondary
restraint to ATT, is greatly increased [810]. ACL in-
suciency may also lead to degenerative changes inside
the knee consistent with osteoarthritis [11,12]. As a
706 T. Yanagawa et al. / Clinical Biomechanics 17 (2002) 705712
result, rehabilitative methods have been sought which
limit ATT in the ACL-decient knee during isokinetic
knee-extension to levels present in the intact joint
[1,13,14].
A large number of in vivo [1520], in vitro [5,21], and
modeling studies [6,2224] have shown that hamstrings
co-contraction can reduce ATT in the ACL-decient
knee. Hamstrings activation may reduce ATT since
these muscles insert on the back of the tibia, and they
may therefore apply a posterior pull to the leg. Imran
and OConnor [23] used a two-dimensional model to
study the eectiveness of hamstrings co-contraction
force on ATT during isometric extension. Their calcu-
lations showed an inverse relationship between ATT and
hamstrings force, with hamstrings co-contraction being
least eective in reducing ATT near extension. These
ndings are well supported by experimental measure-
ments reported by Hirokawa et al. [21]. Relatively little
is known, however, about the amount of hamstrings
activation needed to keep ATT within normal limits
during functional activity. Liu and Maitland [24] esti-
mated the amount of hamstrings activation needed to
stabilize the ACL-decient knee during level walking;
however, their analysis was quasi-static and their nd-
ings apply only to a single instant of the gait cycle. To
our knowledge, no study has reported on the eect of
hamstrings muscle action on stability of the ACL-de-
cient knee during dynamic rehabilitation exercises like
isokinetic extension.
It is also not clear whether hamstrings co-contraction
is more eective in reducing ATT than is low-resistance
extension exercise (i.e., knee-extension at high speeds).
Wilk and Andrews [25] measured ATT in ACL-decient
patients for speeds ranging from 60 to 300 deg/s. They
reported a linear drop in ATT as knee-extension speed
increased, but no comparison of the eect of hamstrings
co-contraction was made.
The main objective of the present study was to
investigate the eect of hamstrings muscle action on
stability of the ACL-decient knee during isokinetic
exercise at various speeds. The analysis was based on
a sagittal-plane model used previously to study load
sharing between the muscles, ligaments, and bones
during isometric knee-extension [6,2628], isokinetic
exercise [7], and squatting [22]. The limit of knee-joint
stability was dened as the peak ATT calculated for
maximum isometric contractions of the quadriceps in
the normal knee in the absence of hamstrings co-con-
traction. Four specic questions were addressed:
(1) What is the relationship between ATT and speed for
isolated contractions of the quadriceps during iso-
kinetic exercise?
(2) What is the relationship between ATT and ham-
strings muscle activation during isokinetic knee-
extension?
(3) Which factor has a greater eect on ATT in the
ACL-decient knee, knee-extension speed or ham-
strings co-contraction force?
(4) In the range of extension speeds currently prescribed
for rehabilitation, what level of hamstrings activa-
tion is needed to stabilize an ACL-decient knee?
Mathematical modeling and forward-dynamics com-
puter simulation were used to address these questions. A
forward-dynamics simulation approach is necessary to
study the relationship between hamstrings muscle acti-
vation and ATT because the level of hamstrings acti-
vation (and ultimately hamstrings co-contraction force)
could be controlled more directly in the model. Also,
high muscle forces generated during isokinetic extension
exercise makes the use of in vitro measurement methods
impractical for determining the dependence of ATT on
quadriceps and hamstrings force.
2. Methods
The model presented in Shelburne and Pandy [27] has
been expanded to permit simulation of an isokinetic
knee-extension activity conducted in a sitting position
with the hip exed to 60. The only structures not xed
to the ground were those distal to the femur. The lower
leg was modeled as a rigid body consisting of a shank
and a foot; the ankle was held xed in the neutral
(standing) position throughout the activity. Because all
motion was conned to the sagittal plane, the lower legs
orientation relative to the thigh was dened by three
generalized coordinates (Fig. 1(A)): anteriorposterior
translation (q1 ), proximaldistal translation (q2 ), and the
angle between the long axis of the femur and the long
axis of the tibia (i.e., the knee-exion angle) (q3 ). Tibio-
femoral contact, which is assumed to be rigid and
frictionless, was enforced via a holonomic constraint.
The tibial plateau, modeled as a at surface sloping 8
posteriorly, made single-point contact with a surface
represented by a two-dimensional quintic spline tted to
the mid-parasagittal section of the lateral femoral con-
dyle (Fig. 1(A)).
The anterior and posterior cruciate ligaments, the
medial and lateral collateral ligaments, and the posterior
capsule were modeled by a total of 11 elastic bundles,
each consisting of a straight-line segment joining the
three-dimensional attachment sites obtained from ex-
periment (Fig. 2(A)). The force developed in each liga-
ment bundle varied nonlinearly with ligament length
and linearly with ligament velocity (the rate of change of
ligament length); parameters assumed for the model
ligaments are given in Serpas et al. [7].
The motion of the lower leg was inuenced by the
action of 11 musculotendinous units (Fig. 1(B)). Each
musculotendinous unit was modeled as a three element
 T. Yanagawa et al. / Clinical Biomechanics 17 (2002) 705712
Fig. 1. (A) The orientation of the lower leg was determined by three
generalized coordinates: anteriorposterior translation (q1 ) and prox-
imaldistal translation (q2 ) were measured in a tibia-xed frame rela-
tive to the approximate center of curvature of the posterior femoral
condyles; knee exion angle (q3 ) was dened as the angle between the
long axes of the femur and tibia. (B) The model simulates an isokinetic
knee-extension activity conducted in a sitting position with the hip
exed to 60 (i.e., the angle between the femur and tibia is 120). The
ankle is held xed in the neutral (standing) position throughout
the activity. Three musclesrectus femoris (RF), vastus medialis
(VMED), and vastus intermedius/lateralis (VINT)were maxi-
mally activated for the duration of the activity. Muscles exing the
kneebiceps femoris long head (BFLH) and short head (BFSH),
semimembranosus (MEM), semitendinosus (TEN) and gastrocnem-
iuswere activated as described in the text. The three remaining
musclesgracilis, tensor fasciae latae (iliotibial tract), and sartorius
contributed only passive forces during the simulations; these muscles
are not shown in the diagram.
muscle in series with a linearly elastic tendon. The
mechanical behavior of muscle was represented by a Hill-
type contractile element that modeled muscles force
lengthvelocity property, a series-elastic element that
modeled muscles active stiness, and a parallel-elastic
element that modeled muscles passive stiness. For the
duration of each simulated exercise, the quadriceps was
fully activated; all other muscles except the hamstrings
were fully deactivated, thus supplying only passive force.
The activation level of the hamstrings was xed at either
0%, 25%, 50%, or 100%. (0% represented complete de-
activation and 100% represented maximum activation.)
For each musculotendinous unit, muscle activation (a),
musculotendon length (lMT ), musculotendon velocity
(vMT ), musculotendon force (F MT ), and the time rate of
change in musculotendon force (F_ MT ) were related by a
nonlinear, rst-order, dierential equation of the form:
707
Fig. 2. (A) The passive structures of the tibiofemoral joint were
modeled by a total of eleven elastic bundles, each consisting of a
straight-line segment joining the three-dimensional attachment sites.
The line segments shown represent the anterior (1) and posterior (2)
bundles of the ACL, the anterior (3) and posterior (4) bundles of the
posterior cruciate ligament, the anterior (5), intermediate (6), and
posterior (7) bundles of the supercial medial collateral ligament, the
anterior (8) and posterior (9) bundles of the deep medial collateral
ligament, the lateral collateral ligament (10), and the posterior capsule
(11). (B) Gastrocnemius, semimembranosus, and semitendinosus were
constrained to follow the shortest distance along appropriately placed
via cylinders. This requirement ensured both that the actuator forces
were applied in the proper orientation and that the muscle lengths were
calculated correctly. Gastrocnemius (GAS) originates at a, wraps
around one of the cylinders, and touches the tibia at b. Semi-
membranosus (MEM) wraps around the same cylinder and inserts at
c. Semitendinosus (TEN) wraps around a dierent cylinder and
inserts at d.
F_ MT f lMT ; vMT ; F MT ; a; where 0 6 a 6 1 1
A straight, origin-to-insertion line of action was em-
ployed for each muscle, except where the muscle con-
tacted and wrapped around bone or another muscle.
The paths of the gastrocnemius, semimembranosus, and
semitendinosus muscles were constrained to follow the
shortest distance along appropriately placed via cylin-
ders (Fig. 2(B)). The paths of the quadriceps muscles
across the patellofemoral joint required special atten-
tion. As with the tibiofemoral joint, rigid and frictionless
708 T. Yanagawa et al. / Clinical Biomechanics 17 (2002) 705712

single-point contact was maintained between a at sur- at the ankle, and the net torque required to maintain the
face (the patella facet) and a two-dimensional quintic machine arm motion at the designated isokinetic speed.
spline (tted to the mid-parasagittal section of the Requiring tibiofemoral contact and prescribing the
femoral groove) (see Fig. 1(A)). The patella (which was motion of the machine arm eectively eliminated 2 of
treated as massless) experienced a proximal force from the 3 degrees of freedom, leaving ATT as the only in-
the quadriceps tendon and a distal force from the pa- dependent generalized coordinate. ATT present during
tellar tendon. The patellar tendon was treated as an the simulations was a function of the net shear force
inextensible element. Static equilibrium dictates that the imparted to the lower leg by the muscles, the distal re-
magnitude and direction of the aforementioned forces straint, tibiofemoral contact, and inertia. Gravity was
and the orientation of the patella be related by a single turned o in the dynamical model to avoid the need
nonlinear equation that can be solved iteratively. Details to account for torque caused by the weight of the lower
of the model used to simulate patellofemoral mechanics leg, and to simulate the conditions under which iso-
are given in Appendix A of Shelburne and Pandy [27]. kinetic knee-extension exercises are actually performed.
The parameters assumed for the model muscles are
given by Serpas et al. [7].
The lower leg was distally constrained by its con- 3. Results
nection to the massless arm of a simulated isokinetic
exercise machine. This machine arm rotated about an ATT was inversely related to extension speed in both
axis coincident with the approximate center of curvature the intact and ACL-decient knee (Fig. 3(A) and (B)).
of the posterior femoral condyles. The interface between The eect of speed on ATT was uniform whether or
the lower leg and the machine consisted of a massless not the ACL was present (Fig. 4). For example, the
cu connected to the arm by a pin joint located 43 cm
from the arms rotation axis. This distance was chosen
to ensure that the restraining force was applied near the
ankle. The cu was free to translate relative to the lower
legs long axis, subject to a small degree of damping.
Equations of motion for the system were obtained
through the use of a computer software package called
SD/Fast. For a given simulation, the angular velocity of
the machine arm was prescribed in SD/Fast with an
inverse tangent function having asymptotes at 0 deg/s
(for the start of the activity) and the desired isokinetic
speed. The function was chosen such that the accelera-
tion to isokinetic speed took place between knee-exion
angles of 105 and 100, before the range to be studied
(905) was reached. Knee-exion angles less than 5
were not included in the simulated range because, in (A)
practice, people do not bring their knees to full exten-
sion during isokinetic exercise.
The dynamical equations of motion for the muscu-
loskeletal knee model can be represented in the form:
x_ f x; t 2
where the state vector contains 28 elements: 3 general-
ized coordinates, q, which dene the position and ori-
entation of the leg relative to the thigh; 3 generalized
speeds, q_ , dened as the time rate of change of the
generalized coordinates; 11 musculotendon forces, F MT ;
and 11 muscle activations, a. Simulations were run by
choosing an isokinetic speed of 30, 90, 180, 300, or 360
deg/s and integrating the equations using a Runge (B)
Kutta, xed-step integrator. Choosing the activations
Fig. 3. (A) ATT calculated for the ACL-intact knee without ham-
and prescribing the motion of the machine arm gave the
strings co-contraction for isokinetic knee-extension at 0, 30, 90, 180,
time-history of the generalized coordinates, the muscu- and 300 deg/s. (B) ATT calculated for the ACL-decient model knee
lotendon forces, the ligament forces, the tibiofemoral without hamstrings co-contraction for isokinetic knee-extension at 0,
and patellofemoral contact forces, the restraining force 30, 90, 180, and 300 deg/s.
 T. Yanagawa et al. / Clinical Biomechanics 17 (2002) 705712
Fig. 4. Peak ATT versus isokinetic speed without hamstrings co-con-
traction for the ACL-intact and ACL-decient knee model. Also
shown are data from Wilk and Andrews [25] for ACL-decient test
subjects.
dierence in ATT between the intact and ACL-decient
knee for isometric extension and for extension at 360
deg/s was around 6.5 mm (compare 0 and 360 deg/s in
Fig. 4). Furthermore, no matter how fast the knee was
extended, peak ATT occurred at 10 of exion for the
ACL-decient knee, and ATT dropped to zero at
around 70 of exion in both the intact and ACL-de-
cient knee (Fig. 3(A) and (B), 10 exion and 7075
exion, respectively). The uniform drop in peak ATT
with increasing speed found for the model ACL-de-
cient knee is consistent with experimental measurements
reported by Wilk and Andrews [25] (Fig. 4).
ATT was inversely related to hamstrings co-contrac-
tion level at all extension speeds (Fig. 5). For all speeds
in the intact joint, ATT dropped by 5 mm when ham-
strings was fully activated (compare ATT at 0% and
100% hamstrings activation at all speeds in Fig. 5(A)).
In the ACL-decient knee, by comparison, ATT de-
creased by roughly 12 mm at all speeds when the ham-
strings were fully turned on (compare ATT at 0% and
100% hamstrings activation at all speeds in Fig. 5(B)).
The decline in ATT was more rapid at lower levels of
hamstrings activation than at higher levels, irrespective
of knee-extension speed (compare Fig. 5(A) and (B) at
025% of hamstrings activation).
Some amount of hamstrings activation was needed at
all speeds to stabilize the model ACL-decient knee.
Although peak ATT decreased as extension speed in-
creased (Fig. 4), the decrease was insucient to prevent
excessive ATT (knee instability), even at the highest
speeds of extension (Fig. 6, unstable region spans all
speeds up to 360 deg/s). However, relatively low levels of
hamstrings activation were needed to stabilize the ACL-
decient knee at the highest speeds. For isometric ex-
tension, the hamstrings must be activated at least 35% of
maximum in order for the model ACL-decient knee to
709
(A)
(B)
Fig. 5. (A) Peak ATT versus hamstrings co-contraction level for iso-
kinetic knee-extension at 0, 30, 90, 180, and 300 deg/s in the ACL-
intact knee. (B) Peak ATT versus hamstrings co-contraction level for
isokinetic knee-extension at 0, 30, 90, 180, and 300 deg/s in the ACL-
decient knee. The horizontal line drawn at 7.5 mm represents the
peak ATT calculated for isometric contractions of the quadriceps
without hamstrings co-contraction; this is the amount of ATT used to
dene the limit of knee-joint stability in the ACL-decient model.
remain stable; in contrast, when the model knee was
extended at a rate of 360 deg/s, only 10% of maximum
hamstrings activation was needed to limit the amount of
ATT and to keep the knee stable (compare 0 and 360
deg/s in Fig. 6).
4. Discussion
Perhaps the most signicant limitation of the analysis
is that the model itself is comparatively simple. The
model knee accounts only for relative movements of the
bones in the sagittal plane. Furthermore, the model
bones are assumed to be rigid, so that there is only point
contact between the femur and tibia and between the
femur and patella. Other simplications incorporated in
the model include modeling the tibial plateau and pa-
tellar facet as at surfaces; neglecting the inuence of the
710 T. Yanagawa et al. / Clinical Biomechanics 17 (2002) 705712
Fig. 6. Amount of hamstrings activation needed to stabilize the ACL-
decient knee in isokinetic extension exercise. The limit of knee-joint
stability was dened as the peak ATT calculated for maximum iso-
metric contractions of the quadriceps (without hamstrings co-con-
traction) in the ACL-intact knee (see horizontal line drawn at 7.5 mm
in Fig. 5(B)).
menisci and cartilage; assuming that the knee ligaments
and muscle tendons are elastic structures; approximat-
ing the paths of the knee ligaments as straight lines, and
neglecting the eects of contact between the ligaments
and bones; and nally, assuming that the external re-
straining force acts at a single point on the leg. Many of
these limitations have previously been discussed and
justied [7,27,28].
The model bones were conned to move in the sag-
ittal plane, which excludes axial rotation experienced by
the shank during extension of the knee in vivo. The ef-
fect of this rotation is to decrease the force borne by the
ACL, which means that the model predictions of ATT
may be somewhat higher than those experienced in the
living knee. The reasoning is as follows. Markolf et al.
[29] (see Fig. 4 in their paper) found that both external
and internal torques applied to the tibia increase ACL
force near full extension. Now, as the intact knee ex-
tends, the tibia rotates externally relative to the femur;
at full extension, the tibia can be rotated by as much as
20 externally. This means that if the tibia was con-
strained to move in the sagittal plane, an internal torque
would have to be applied to the tibia in order to bring it
to the neutral position at full extension. Markolfs re-
sults show that internal torques increase ACL force.
Thus, the eect of constraining the tibia to move in the
sagittal plane is to increase ACL force, which means
that a sagittal-plane model of the knee would over-
estimate ACL force. Because an increase in ACL force is
ultimately the result of an increase in ATT, we may
conclude that a sagittal-plane model of the knee over-
estimates ATT as well.
The results of in vitro experiments performed on the
ACL-intact knee indicate that anteriorposterior laxity
does not change much when the menisci are removed.
However, when the medial meniscus is excised subse-
quent to sectioning the ACL, anterior laxity increases
considerably [30]. This nding suggests that the menis-
cus plays an important role in providing anterior sta-
bility to the ACL-decient knee. To compensate for the
absence of a meniscus in the model, the stiness of the
secondary ligaments were adjusted until anterior laxity
in the ACL-decient model matched in vitro data re-
ported in the literature (see Fig. 4(A) in [6]). The cal-
culated values of ATT for the ACL-decient model are
therefore presumed to approximate the values of ATT
present in the real ACL-decient knee for isokinetic
extension exercise (see also Fig. 5(B) in [6]).
The aforementioned limitations notwithstanding, the
predictions of the model are consistent with trends re-
ported previously by others. Nisell et al. [31], Kaufman
et al. [32], Baltzopoulos [33], Escamilla et al. [34], and
Toutoungi et al. [35] all found peak tibial shear forces to
be less than 1 body weight (BW) for isokinetic knee-
extension exercises ranging in speed from 30 to 300 deg/s
in the intact knee. There is also a consensus among these
studies that the magnitude of the peak tibial shear force
decreases as extension speed increases. For example,
Nisell et al. [31] and Baltzopoulos [33] predicted peak
tibial shear forces of around 0.9 BW when the knee
extended at 30 deg/s, and peak shear forces ranging from
0.7 to 0.8 BW when knee-extension speed exceeded 200
deg/s. For the model used in this study, peak tibial shear
forces decreased from 0.7 BW at 30 deg/s to 0.4 BW
when the knee extended at 300 deg/s.
The calculated values of ATT also agree with in vivo
measurements of ATT obtained for the intact and ACL-
decient knee. Kizuki et al. [36] found peak ATT for
knee-extension performed at 30 deg/s to be around 10
mm for the intact knee and around 15 mm for the ACL-
decient knee. The model calculations show peak ATT
at 30 deg/s for the intact and ACL-decient knee to be
6.8 and 13.5 mm, respectively. The model also correctly
predicts that peak ATT should occur somewhere be-
tween 10 and 20 of exion in both the intact and ACL-
decient knee. Wilk and Andrews [25] measured ATT in
vivo for isokinetic knee extension at speeds ranging
from 60 to 300 deg/s. Their results showed that ATT
decreased linearly as extension speed increased in the
ACL-decient knee, with peak ATT being 16.1 mm
when the knee was extended at 60 deg/s, and decreasing
to 11 mm when the knee was extended at a much faster
rate of 300 deg/s. Fig. 4 indicates that the model simu-
lations reproduce the uniform decrease in ATT with
increasing knee-extension speed, and that the rate of this
decrease is also consistent with that found from exper-
iment (compare slopes of experimental and model data
for the ACL-decient knee).
The inverse relationship between ATT and extension
speed for both the intact and ACL-decient knee is ex-
plained by the forcevelocity property of the quadriceps
 T. Yanagawa et al. / Clinical Biomechanics 17 (2002) 705712
muscles in the model. ATT decreased as extension speed
increased (Fig. 4) because the forces developed by the
quadriceps are a function of speed. As extension speed
increases, the contraction velocities of the quadriceps
increase, so that (for a given exion angle) the resultant
force transmitted to the quadriceps tendon (and thus to
the patellar tendon) decreases, and the anterior shear
force applied to the leg is lower [7].
The inverse relationship between peak ATT and
hamstrings activation is explained by the ability of these
muscles to apply a posterior pull to the tibia at all
exion angles, except near extension. Peak ATT de-
creases as hamstrings activation increases because the
posterior shear force provided by these muscles over-
whelms the anterior shear forces supplied by the patellar-
tendon force and the tibiofemoral compressive force.
Even at small exion angles (between 10 and 15), for
which the hamstrings insert steeply on the back of the
tibia, co-contraction of these muscles is still eective in
reducing ATT because hamstrings develop their maxi-
mum forces when the knee is near extension [27].
Hamstrings co-contraction decreases peak ATT in
both the intact and ACL-decient knee, but for any
given speed the eect is greater when the ACL is absent.
The results of Fig. 5 show that activating the model
hamstrings to 30% of its maximum value reduces ATT
by 6.5 mm in the ACL-decient knee, compared with
only 2.5 mm in the intact knee (compare ATT for 030%
hamstrings activation in Fig. 5(A) and (B)). Hamstrings
co-contraction is more eective in reducing peak ATT
when the ACL is absent because the shear force applied
by the patellar tendon is smaller in this case [6]. The
patellar-tendon shear force is smaller because the angle
between the patellar tendon and the tibial long axis is
smaller, which occurs because tibiofemoral translation is
greater in the ACL-decient knee.
Despite the emphasis on weight-bearing exercises in
most ACL rehabilitation protocols, the use of isokinetic
knee-extension exercises to train or assess quadriceps
muscular strength is still common in the eight weeks to
six months post-injury and post-operative periods [14].
Thus, it is clinically relevant to determine the eect of
hamstrings muscle action and isokinetic speed on the
stability of the ACL-decient knee during isokinetic
exercise. First, we found, in agreement with experi-
mental results reported by others [25], that slow-speed
isokinetic exercise (30 deg/s) produces higher peak ATT
values than fast speeds (300 deg/s and above). Clinically,
this nding suggests that high-speed or low-resistance
extension exercise can be used during the early phases of
a rehabilitation training program for the ACL-recon-
structed knee, at least until adequate graft maturation
and strength have occurred.
Secondly, if isokinetic extension protocols are to be
designed to increase joint stability by reducing ATT,
then the results of Figs. 4 and 5 indicate that hamstrings
711
co-contraction is more eective than low-resistance ex-
tension exercise for the conservative treatment of an
ACL-decient knee. The model simulations show that a
1 mm reduction in ATT requires only a 5% increase in
hamstrings activation, but that extension speed must be
increased by roughly 100 deg/s before a similar reduc-
tion in ATT can be obtained (compare slopes of curves
for ACL-decient knee in Figs. 4 and 5). Given that
lower speeds yield higher quadriceps forces, these nd-
ings suggest that for quadriceps strengthening it is more
benecial to exercise at lower extension speeds, provided
that the hamstrings can be contracted with sucient
force to keep ATT within an allowable limit (Fig. 6).
Finally, we found that although peak ATT decreased
as extension speed increased, some amount of ham-
strings co-contraction was always needed to stabilize the
model ACL-decient knee (Fig. 6). If a rehabilitation
program is to include isokinetic exercise as an adjunct
to thigh muscle strengthening, it will be important to
ensure that the ACL-decient patient is capable of co-
contracting his/her hamstrings during this exercise;
otherwise, excessive ATT over time may cause damage
to the menisci and other passive structures, resulting
in further degeneration of the joint. Hamstrings co-
contraction is also critical for the patient with an ACL-
reconstructed knee, because excessive ATT in this case
will risk damage to the immature graft and/or xation.
Some studies have shown that anterior knee stability can
be improved in an ACL-decient population by training
these patients to alter their muscle recruitment patterns
during activity [37,38]. Further research is needed to
understand the eects of changes in muscle coordination
versus muscle strength training on ATT in the ACL-
decient knee.
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