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THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 31, No. 5
2003 American Orthopaedic Society for Sports Medicine

The Effects of Compressive Load and Knee

Joint Torque on Peak Anterior Cruciate
Ligament Strains*
Braden C. Fleming, PhD, Goran Ohlen, MD, Per A. Renstrom, MD, PhD,
Glenn D. Peura, MS, Bruce D. Beynnon, PhD, and Gary J. Badger, MS

From the McClure Musculoskeletal Research Center, Department of Orthopaedics and

Rehabilitation, and the Department of Medical Biostatistics, University of Vermont,
Burlington, Vermont, and the Section of Sports Medicine, Division of Orthopaedics,
Karolinska Hospital, Stockholm, Sweden

Background: High graft strains incurred during rehabilitation after anterior cruciate ligament reconstruction may be minimized
if an external compressive load is simultaneously applied to the joint during closed kinetic chain exercises.
Hypotheses: Peak anterior cruciate ligament strains will 1) increase with an increase in resistance torque during an exercise
that involves concentric contraction of the extensor mechanism, 2) decrease with an increase in resistance torque during an
exercise that involves concentric contraction of the flexors, and 3) decrease when an external compressive load is applied to the
knee during both exercises relative to the no external compressive load condition.
Study Design: Controlled laboratory study.
Methods: Strains in the anteromedial bundle were measured in 10 subjects with normal ligaments. Flexor and extensor
exercises were performed against controlled resistance torques with and without a compressive load applied to the foot.
Results: An increase in resistance produced an increase in peak anterior cruciate ligament strain for the extensor exercise with
no compressive load applied. During the flexor exercise without a compressive load, an increase in resistance produced a
decrease in peak strains. During the extensor exercise, the peak anterior cruciate ligament strain was not reduced with the
application of the external compressive force.
Conclusions: Extensor and flexor exercises that incorporate an external compressive load do not shield the anterior cruciate
ligament from strain. However, no additional increase in strain occurs with an increase in resistance when the external
compressive load is applied. Thus, it may be possible to increase the activity of the quadriceps muscles without increasing the
strain by applying a compressive load (as with closed kinetic chain exercises).
2003 American Orthopaedic Society for Sports Medicine

The optimal means of rehabilitation after ACL reconstruc-
tion remains controversial because there is little agree-
ment about the effects of the combined loads produced by
muscle contraction and body weight on the knee and heal-
ing ACL graft. Closed kinetic chain exercises, such as
squats, are thought to protect the ACL graft because they
incorporate co-contraction of the quadriceps and ham-
* Presented at the annual meeting of the AOSSM, Orlando, Florida, July
2002, and at the Orthopaedic Research Society meeting, Dallas Texas, Feb-
ruary 2002.
Address correspondence and reprint requests to Braden C. Fleming,
PhD, Rhode Island Hospital, Bioengineering Laboratory, CORO West, Suite
404, 1 Hoppin Street, Providence RI 02903
No author or related institution has received any financial benefit from
research in this study. See Acknowledgments for funding information.
string muscles and include the tibiofemoral compressive
load produced by body weight, which is thought to inter-
lock the articulating surfaces and reduce anterior tibial
translation.15, 27, 33, 37, 38 In contrast, open kinetic chain exer-
cises, such as leg extensions, are thought to place the healing
graft at risk because they require quadriceps-dominated leg
muscle contractions and do not include the protective com-
pressive load produced by body weight.15, 27, 33, 37 However,
there is evidence to suggest that the tibiofemoral compres-
sive load produced by body weight can shift the tibia anteri-
orly relative to the femur,6, 36 which in turn could strain the
ACL.18 Also, co-contraction of the knee musculature has
been shown to strain the ACL when the knee is near exten-
sion.19 Thus, the perceived advantages of closed kinetic
chain exercises may be suspect. Direct measurements of the

701
702 Fleming et al.
ACL strain response have shown that the peak strains are
similar for active extension and for squats, which brings into
question the protective mechanisms that are thought to be
associated with closed kinetic chain exercises.8 However,
because the kinematics and loading conditions between
these two activities are different, it is not possible to isolate
the effect of the compressive load caused by body weight or
its interaction with the muscle activity level required for
resistance of an externally applied resistance torque. Thus,
there was a need to evaluate the effects of external tibiofemo-
ral compressive loads and resistance torques on the ACL
strain response in a controlled manner.
The objective of this study was to compare the peak ACL
strains produced during concentric knee extensor and
flexor exercises when they are performed against different
resistance torques, both with and without a compressive
load applied to the foot. These exercises are representative
of closed and open kinetic chain activities when performed
with and without the compressive load, respectively. Our
research hypotheses were that peak ACL strains will 1)
increase with an increase in resistance torque during ex-
ercises that involve concentric contraction of the extensor
muscles; 2) decrease with an increase in resistance torque
during exercises that involve concentric contractions of
the knee flexors; and 3) decrease when an external com-
pressive load is applied to the knee during both exercises
relative to the no external compressive load condition. For
this study we assumed that exercises producing high
strains on the anteromedial bundle of the ACL would
produce high strains in the ACL graft.
MATERIALS AND METHODS
Test Subjects
Ten patients (7 men and 3 women) who were candidates
for arthroscopic partial medial meniscectomy (3 patients),
partial lateral meniscectomy (4 patients), plica excision (2
patients), or patellar chondral debridement (1 patient)
participated in the study. Their ages ranged from 20 to 49
years, with a mean age of 33 years. No patient had a
history of a knee ligament injury. All surgeries were per-
formed with local anesthesia that consisted of a mixture of
bupivacaine and chloroprocaine hydrochloride, which was
injected into the joint capsule. Normal ligament function
was verified at the time of surgery through clinical exam-
ination of the knee and arthroscopic palpation of the ACL.
The study was approved by the Institutional Review
Board of the University of Vermont and the Ethics Com-
mittee of the Karolinska Hospital, and all patients
granted their informed consent before participating.
Strain Measurement Device
Displacements of the anteromedial bundle of the ACL
were measured by using a differential variable reluctance
transducer (DVRT; MicroStrain, Burlington Vermont).4
The small displacement transducer was arthroscopically
implanted into the ligament through the lateral parapa-
tellar portal with the knee at 45 of flexion. The meas-
American Journal of Sports Medicine
urement axis of the DVRT was visually aligned with the
fibers of the ligament bundle as viewed through the ar-
throscope, and the two fixation barbs of the sensor were
then pressed into the tissue (Fig. 1). The electrical connec-
tion and removal sutures of the DVRT coursed through
the lateral portal and were strapped to the thigh to enable
data acquisition and permit transducer removal after the
experiment. The arthroscopic portals were sealed with a
sterile dressing (Tegaderm; 3M Healthcare, St. Paul, Min-
nesota) during the experimental protocol.
The displacement measurements were converted to
strains by using the engineering strain formulation.4, 7, 17
The reference length selected for the strain calculations
corresponded to the slack-taut transition length of the
anteromedial band with the knee at 30 of flexion as
previously described and verified by our group.17 The ref-
erence was obtained by applying anterior-posterior shear
loads to the tibia relative to the femur (as with an instru-
mented Lachman test) while the displacement response of
the ligament was measured. The DVRT length corre-
sponding to the inflection point of the load-displacement
curve served as the reference.7, 17
Exercise Bench
With the use of a custom-fabricated exercise bench,
torques (flexion and extension) were applied directly to
the knee of the subject. Subjects resisted the applied flex-
ion torque through contraction of the quadriceps muscles;
applied extension torque was resisted through contraction
of the hamstring muscles (Fig. 2). During the extensor
dominant exercise, the extensor muscles resisted the ap-
plied flexion torques. During the flexor dominant exercise,
Figure 1. The DVRT was inserted arthroscopically into the
anteromedial band of the ACL.16 The body of the transducer
is approximately 5 mm in length. The fixation barbs are 3 mm
long and penetrate into the ligament. Therefore, the DVRT
provides a mechanical average of the peak strains produced
in the midsubstance of this region. (Reprinted with permis-
sion from Fleming et al.16)
Vol. 31, No. 5, 2003 Compressive Load and Knee Joint Torque: Effect on Peak ACL Strains
Figure 2. The test fixture produced flexion and extension
torques at the knee by the use of free weights and a bicycle
wheel. In this drawing, the device is set up to deliver a flexion
torque by hanging free weights from the cable that is
wrapped clockwise about the wheel (dashed gray arrow).
Extension torques were applied to the knee by applying the
weights to the cable wrapped counterclockwise about the
loading wheel. Free weights were also used to apply a com-
pressive load to the foot and increase the compressive load
on the tibiofemoral joint. The compressive loads (black ar-
rows) were delivered to the bottom of the foot via a cable and
pulley mechanism that applied the loads to the footplate
through the linear bearing track. The footplate did not contact
the bottom of the foot and was locked when the compressive
loads were removed.
the flexor muscles resisted the applied extension torques.
The exercise bench enabled the subjects to perform the
extensor and flexor exercises with and without an exter-
nal compressive load applied to the knee (Fig. 2). For this
study, flexion and extension torque magnitudes of 0, 12,
and 24 Nm were applied to the knee. It should be noted
that the 0 Nm resistance requires the subject to flex and
extend the knee against the torque produced by the action
of gravity on the lower leg. We selected these resistive
torques because they are within the range of those typi-
cally used by patients performing quadriceps and ham-
string muscle exercise sets during rehabilitation, and all
subjects were capable of achieving these values. When the
compressive load was engaged, a force equal to 40% body
weight was applied to the foot and directed along the
longitudinal axis of the tibia. This load was selected be-
cause it is equal to approximately one-half of the subjects
weight that is distributed above the knee.40 The knee
703
flexion angle was measured during the exercises by using
a potentiometer mounted to the flexion-extension (loading
wheel) axis of the exercise bench (Fig. 2).
Experimental Protocol
Immediately after the routine surgical procedure, while
the patient remained in the operating room, the DVRT
was implanted onto the anteromedial bundle. After im-
plantation of the sensor, each subject was seated on the
exercise bench, which was attached to the operating table.
Subjects were seated such that the epicondylar axis of the
knee was collinear with the loading wheel axis of the
exercise bench (Fig. 2). The epicondyles were palpated to
identify the epicondylar axis. The position of the loading
wheel axis was then adjusted relative to the exercise
bench seat (hence, the knee joint) to ensure proper align-
ment. The potentiometer that measured the knee flexion
angle was initialized with the knee at 90 of flexion. The
output of the potentiometer was checked with a goniome-
ter to ensure an accurate knee flexion angle reading over
the range of knee flexion-extension motion.
The extensor and flexor exercises were performed
against the resistance torque magnitudes (0, 12, and 24
Nm) with and without the compressive load applied (40%
and 0% body weight). A randomization procedure (blocked
by exercise type, compressive load state, and resistance
torque magnitude) was used to establish the exercise test
order. Subjects were instructed to flex and extend their
knees from 90 of flexion to approximately 10 of exten-
sion. Full extension (0) was avoided to prevent impinge-
ment of the DVRT against the roof of the femoral inter-
condylar notch. Three cycles (approximately 4 seconds per
cycle) of each exercise were performed with and without
the compressive load applied to the knee. Data were re-
corded from the DVRT and the knee flexion angle poten-
tiometer during the eccentric and concentric contractions
of each load cycle. The first cycle was used to help the
patient establish the flexion-extension limits of the test
and to set the cadence. The second and third cycles were
averaged and used in the statistical analysis.
Both before and immediately after the test protocol, an
instrumented Lachman test was performed. Anterior-pos-
terior directed shear loads, between the limits of 90 N
(posterior) and 130 N (anterior), were applied to the
tibia while the knee was supported at 30 of flexion with
the femur aligned in the horizontal plane.4 The shear
loads were applied perpendicular to the long axis of the
tibia at the level of the tibial tuberosity. The subjects were
instructed to relax their leg musculature during the test,
although muscle tension was not objectively measured.
The load versus DVRT displacement data obtained from
these tests served two purposes: 1) to determine the ref-
erence for the strain calculation as described earlier,17
and 2) to serve as a repeated normal to ensure that the
DVRT measurements were reproducible before and after
the exercise session.7 After completion of the final instru-
mented Lachman test, the lateral arthroscopic portal was
reopened and the DVRT was removed. The incisions were
704 Fleming et al. American Journal of Sports Medicine

then closed by following routine procedures used for ar-

throscopic surgery.

Data Analysis

Tests for differences in peak ACL strains (the dependent

variable) across experimental conditions were performed
by using a three-way repeated measures analysis of vari-
ance (ANOVA). The three within-subject factors (the in-
dependent variables) were exercise type (extensor versus
flexor), compressive load state (0% versus 40% body
weight), and resistance torque magnitude (0 versus 12
versus 24 Nm). After determining that torque-dependent
changes in peak strain varied as a function of exercise
type and compressive load (that is, a significant three-way
interaction), the torque effects were examined within each
of the four experimental conditions by using a one-way
repeated measures ANOVA. Orthogonal polynomials were
used to partition the sums of squares into quantitative Figure 3. Mean peak ACL strain values produced during the
components (that is, linear and quadratic). Strain in- extensor exercise (extensor dominant) with and without the
creases (or decreases) as a function of torque were exam- external compressive load applied to the foot. Significant
ined based on the F-test corresponding to the contrast increases in peak ACL strain occurred as a function of resis-
representing the linear component. The strain reference tance when no external compressive load was applied (P
values obtained from the repeated measures Lachman 0.002). No significant increase as a function of resistance
tests before and after the exercise sessions were also com- torque occurred when the external compressive load was
pared by using a paired t-test to ensure that the DVRT applied (P 0.19). Error bars represent 1 standard error.
measurements were reproducible.7 Statistical significance
was determined by using 0.05. The analyses were
performed with SAS statistical software (Version 8.2; SAS
Institute Inc., Cary, North Carolina).

RESULTS
The strain patterns of the anteromedial bundle of the ACL
as a function of knee flexion angle for the flexor and
extensor exercises were similar to those previously ob-
served for the squatting exercise.8 Strains increased as
the knee was moved from a flexed to an extended position.
The peak strains occurred as the knee neared extension.
The anteromedial bundle was not strained when the knee
was at 90 of flexion.
The average peak strains were dependent on exercise
type (P 0.001). As expected, the leg extensor exercise
produced peak ACL strains (pooled mean 1 standard
error 3.1% 0.51%) that were 82% greater than those
Figure 4. Mean peak ACL strain values produced during the
produced during the flexor exercise (1.7% 0.58%).
flexor exercise (flexor dominant) with and without the exter-
The effect of resistance torque on the peak strains was
nal compressive load applied to the foot. Significant de-
dependent on exercise type and whether the external com-
creases in peak ACL strain occurred as a function of resis-
pressive load was applied (P 0.011 for the three-way
tance when no external compressive load was applied (P
interaction). For the extensor exercise, increases in resis-
0.001). No significant change in peak ACL strain occurred as
tance produced significant increases in ACL strains when
a function of resistance torque when the external compres-
no external compressive load was applied (P 0.002) (Fig.
sive load was applied (P 0.61). Error bars represent 1
3). Application of the compressive load during the exten-
standard error.
sor exercise resulted in similar strain values at 0 Nm of
resistance when compared with the no compressive load
state and, thus, did not reduce the strain on the ligament.
However, there was no evidence of a significant change in with increases in resistance without the compressive load
peak strain with subsequent increases in resistance (0 to present (P 0.001) (Fig. 4). The flexor exercises resulted
24 Nm) (P 0.19) (Fig. 3). During the flexor exercises, in observations similar to those for the extensor exercises;
significant decreases in ACL strain values were observed no significant changes in peak strains were observed with
Vol. 31, No. 5, 2003 Compressive Load and Knee Joint Torque: Effect on Peak ACL Strains
increases in resistance when the compressive load was
applied (P 0.61) (Fig. 4).
For the instrumented Lachman tests that were per-
formed before and after the exercise session, the mean
difference in the reference lengths across subjects was
equal to 0.01 0.016 mm. Because this mean change was
not clinically relevant or statistically significant (P
0.23), the output of the DVRT over the exercise session
bout was considered reproducible.
DISCUSSION
The results of this experiment provide evidence to support
the first two research hypotheses over the range of resis-
tive torque and compressive load values that were tested.
We found that an increase in resistance significantly in-
creased peak strains in the anteromedial bundle of the
ACL during extensor exercise without an external com-
pressive load applied to the foot (Hypothesis 1). The oppo-
site was found for the flexor exercise; increases in resis-
tance significantly decreased peak strains without the
presence of the external compressive load applied to the
foot (Hypothesis 2). The results concerning Hypothesis 3
proved to be resistance torque-dependent. There was not a
significant reduction in peak strain values for either ex-
ercise type when the compressive load was applied to the
foot in conjunction with the 0 Nm external resistance
torque (other than the torque induced by gravity). How-
ever, an increase in resistance torque did not produce a
significant increase in peak ACL strain (a 22% increase
was observed from 0 to 24 Nm of resistance torque) for the
extensor exercise with the external compressive load as
compared with that of the no compressive load condition (a
66% increase was observed from 0 to 24 Nm of resistance
torque). This finding suggests that the external compres-
sive load may attenuate peak strains with additional in-
creases in muscle activity. In contrast, the compressive
load eliminated the reduction in peak strains that oc-
curred with an increase in resistance during the flexor
exercise. Since the peak strains for the flexor exercise
were substantially less than those of the extensor exer-
cise, the impact that the flexor exercise may have on the
healing ACL graft may be negligible.
Studies have shown that compressive loads on the tib-
iofemoral joint decrease anterior knee laxity and increase
knee joint stiffness.1, 6, 28, 36 These findings have led to the
popular belief that a compressive load may protect the
ACL graft because less anterior tibial translation occurs
relative to the femur and, therefore, less strain is placed
on it. However, an anterior shift of the tibia relative to the
femur has been documented for the ACL-deficient knee as
it undergoes the transition from nonweightbearing to
weightbearing.6, 36 This finding is most likely due to the
application of the compressive load applied to the foot and
the activation of the musculature to balance that load,
suggesting that there may be a prestraining effect on the
ACL graft. This prestraining effect has been verified in
ACL-intact knees18, 26 and is most likely caused by the
combination of extensor muscle activity and the anterior
component of the contact force vector (caused by the pos-
705
terior tilt of the surface of the tibial plateau).18, 26, 36 Con-
traction of the leg musculature produces a compressive
load on the tibiofemoral joint that is irrespective of the
compressive load produced by body weight. This study
demonstrates that the addition of a compressive load to
the foot does not eliminate strain in the anteromedial
bundle of the ACL and, hence, in the ACL graft.
On average, the peak ACL strains produced by the exten-
sor exercise were 82% greater than those created by the
flexor exercise. This result would be expected, because the
quadriceps muscles, which are antagonistic to the ACL, are
dominant during extensor exercise.5, 13, 14, 20, 22, 29, 32, 34, 36
During the flexor exercise, the hamstring and gastrocnemius
muscles (the knee flexors) resist the applied extension mo-
ment. Although the concentric flexor exercise produced
strains that were less than those of the concentric extensor
exercise, the ACL remained strained when the knee was
near extension. This result may be explained by the orien-
tation of the hamstring muscles line of action when the knee
is near extension, and by the co-contraction of the hamstring,
quadriceps, and gastrocnemius muscles.32 When the knee is
flexed, the line of action of the hamstring muscles is directed
posteriorly, and contraction of this muscle group pulls the
tibia posteriorly relative to the femur, thereby reducing the
strain on the ACL.13, 32 However, as the knee is extended,
the line of action is directed superiorly rather than posteri-
orly, causing the joint compressive force to increase as the
tibia is pulled toward the femur.32 Isometric contractions of
the gastrocnemius muscle have been shown to strain the
ACL when the knee is between full extension and 30 of
flexion19; thus, gastrocnemius muscle activity could poten-
tially contribute to the strain response. Another contributor
could be the cam effect produced by the increase in the radii
of curvature of the femoral condyles at the point of tibiofemo-
ral contact in the sagittal plane. Thus, the peak strains that
were produced as the knee approaches extension were ex-
pected during the flexor-dominated activities.
After ACL reconstruction, most sports medicine physi-
cians recommend accelerated rehabilitation to minimize
muscle atrophy and maximize joint function as quickly as
possible without damaging the healing graft. These pro-
grams typically incorporate the early use of closed kinetic
chain exercises followed by open kinetic chain exercises
after healing has occurred.11, 30, 33, 35 The rationale for this
approach is based on biomechanical models of the lower
extremity that have shown that the tibiofemoral compres-
sive forces and muscle co-contractions are greater in
closed kinetic chain exercises than in open kinetic chain
exercises and that they produce a net posterior shear load
on the tibia that is thought to protect the ACL.15, 27, 33, 35, 41
However, this study revealed that the ACL strains with
and without the compressive load applied to the foot were
equal to those previously reported for active extension (an
open kinetic chain exercise) and squatting (a closed ki-
netic chain exercise).8
This study enabled us to independently evaluate the
effects of the external compressive load and its interaction
with joint torque (resistance) while standardizing the
range of knee motion, orientation of the limb segments
relative to the loads produced by gravity, and the segment
706 Fleming et al.
velocities for both the open and closed kinetic chain con-
ditions. In this controlled experiment, no strain reduction
was observed when the external compressive load was
applied (the 0 Nm conditions for the extensor and flexor
exercises). During the extensor exercise, a 66% and a 22%
increase in the average peak strains were observed for the
no compressive load and compressive loading conditions,
respectively. Therefore, a reduction in peak strain did not
occur during application of the compressive load. How-
ever, once the compressive load was applied, it signifi-
cantly attenuated the increase in peak strain that occurs
with additional resistance and no external compressive
load. During the flexor exercise, a 77% and an 11% respec-
tive decrease in average peak strains was observed. Al-
though the strain threshold that is deleterious to graft
healing remains unknown, both open and closed kinetic
chain extensor exercises produce significant strains on the
ACL. However, open kinetic chain exercises could place
the graft at additional risk during healing when high
resistances are applied because of the lack of the external
compressive load.
The results of randomized controlled studies that com-
pared the effects of open and closed kinetic chain exercises
on surgical outcome remain controversial.11, 21, 30, 31 By-
num et al.11 performed the first randomized controlled
trial comparing open and closed kinetic chain exercises
after ACL reconstruction with patellar tendon autograft.
The patients assigned to the open kinetic chain exercise
group had a significant increase in anterior knee laxity
compared with those in the closed kinetic chain group
after 1 year of healing. In contrast, in a similar study in
which they attempted to control confounding variables,
Morrissey et al.31 found no differences in anterior-poste-
rior laxity values between the open and closed kinetic
chain treatment groups. Using gait analysis techniques in
patients who had undergone ACL reconstruction, Hooper
and associates21 did not find any clinically significant
differences between the open and closed kinetic chain
rehabilitation groups. Recently, Mikkelsen et al.30 com-
pared postoperative rehabilitation programs that included
both open and closed kinetic chain exercises in the early
phase to one that involved only closed kinetic chain exer-
cises. They determined that the patients in the combined
exercise group significantly increased their quadriceps
muscle function and returned to sport earlier than those
in the closed kinetic chain exercise group, although no
differences were found with regard to anterior knee laxity
between groups. The studies in which no differences in
anterior-posterior laxity were found suggest that the peak
ACL strains between the open and closed kinetic chain
exercises are not clinically different.30, 31 Although the
simulated closed kinetic chain exercise of our investiga-
tion did not reduce the peak strain values of the antero-
medial bundle, they attenuated the strains when higher
resistance torques were applied, suggesting that these
exercises may be used to increase muscle activity about
the knee without added harm. There may be other advan-
tages to the use of closed kinetic chain exercises. Because
closed kinetic chain exercises are functionally similar to
many of the activities of daily living, they may enhance
American Journal of Sports Medicine
proprioception and reduce patellofemoral pain as com-
pared with open kinetic chain exercises.11 Only through
well-designed clinical trials will we be able to establish the
clinical relevance of the strain differences.
This study was performed in subjects with normal ACLs
so that we could gain insight into the peak strains pro-
duced on the graft after ACL reconstruction. It is neces-
sary to perform these experiments in vivo to preserve
physiologic muscle function. It is currently not possible to
directly measure strain in the ACL graft during muscle-
controlled activities because ACL reconstruction should
not be performed with the patient under local anesthesia.
However, it seems reasonable to extend these data to a
properly positioned ACL graft because the displacement
patterns between the graft and normal ACL under passive
(muscles relaxed) conditions are similar.9
The results of this study were based on subjects under-
going arthroscopic surgery with local anesthesia for par-
tial meniscectomy, chondral debridement, or plica exci-
sion. The experiment was performed after the routine
surgical procedure. Although eight of the subjects had
meniscal or minor cartilage problems, the overall function
of their knee joints was considered normal. Complete me-
dial or lateral meniscectomy does not alter knee kinemat-
ics except when the knee is at full extension or when it is
ACL-deficient.2, 24, 25 Thus, it seemed reasonable to as-
sume that partial meniscectomy would have a negligible
effect on the overall kinematics of the knee joint and, thus,
the ligament strain behavior. We also do not expect that
excision of a plica would affect the biomechanics of the
knee. A plica is a ridge or fold of extraneous soft tissue
with no known biomechanical function that is occasionally
found in some knees. The effects of local anesthesia on gait
pattern and proprioception have also been shown to be
negligible.3
The DVRT allowed for precise strain measurements of
the anteromedial aspect of the ACL. It is not capable of
detecting changes in the posterolateral bundle. Applica-
tion of multiple DVRTs could potentially provide a de-
tailed mapping of the strain distribution across the differ-
ent bundles of the ACL. However, the size of the DVRT
and the location of the ACL relative to the PCL and the
intercondylar notch limited us to measuring the antero-
medial bundle using one transducer only. We recognize
that the ACL has a strain distribution about its cross-
section,10 and that the results should not be extrapolated
to the posterolateral bundle. Nonetheless, strain meas-
urements of the anteromedial bundle are important be-
cause, when performing an ACL reconstruction, surgeons
attempt to reconstruct the anteromedial bundle so as to
restore its function.23, 39
Another potential source of error in this study is mal-
alignment of the leg on the exercise bench. The knee does
not move as does the pinned hinge of the loading wheel of
the exercise bench. As the knee axis of rotation moves
relative to that of the loading wheel, tibial translations
could occur that would influence the shear and compres-
sive forces applied to the knee. However, we believe that
such errors are relatively small. It has been shown that
proper alignment of the epicondylar axis will minimize the
Vol. 31, No. 5, 2003 Compressive Load and Knee Joint Torque: Effect on Peak ACL Strains
coupled tibial translations that would induce these forc-
es.12 The test bench was designed so that the location of
the loading wheel axis could be adjusted relative to the
knee, and care was taken to align the epicondylar (flexion-
extension) axis of the knee and the loading wheel to help
minimize these errors. Most likely, the steps taken to
ensure proper limb alignment were at least as good as
those used in a rehabilitation clinic when patients are
exercising the lower-limb musculature.
We conclude that extensor and flexor exercises that
incorporate an external compressive load application to
the foot, such as that produced by body weight, do not
shield the ACL from strain. However, the increase in
strain that occurs with an increase in resistance torque is
less when the external compressive load is applied. Future
studies should be aimed at establishing the strain thresh-
olds that are beneficial and detrimental to graft healing so
that exercise programs can be designed to optimize graft
healing. These data will be useful for designing clinical
studies to optimize rehabilitation protocols.
ACKNOWLEDGMENTS
Funding for this study was received from the National
Football League Charities. The experiment was performed
at the Karolinska Hospital. We gratefully acknowledge
the invaluable contributions of To nu Saartok, MD, Joseph
Abate, MD, Bjarne Brattbakk, PT, Margaret Olmedo, MD,
and Annette Heijne in helping with the experiment.
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