You are on page 1of 10

[

RESEARCH REPORT

RAFAEL F. ESCAMILLA, PT, PhD, CSCS, FACSMD7?GK7DP>;D="PhDJEH7D:$C79B;E:"MPT, MS


W. BRENT EDWARDS, MS47B7D>H;B@79"PhD5=B;DDI$<B;?I?="PhD6A;L?D;$M?BA"DPT7
CLAUDE T. MOORMAN, III, MD8HE:D;O?C7CKH7"PhD9@7C;IH$7D:H;MI" MD10

Patellofemoral Joint Force


and Stress Between a Shortand Long-Step Forward Lunge
he forward lunge is a common weight-bearing exercise
used by athletes and other individuals with healthy knees
to train hip and thigh musculature. Physical therapists
also employ forward lunges and similar weight-bearing
exercises for the rehabilitation of individuals with knee injuries and
pathologies, including patellofemoral rehabilitation for patients with

T STUDY DESIGN: Controlled laboratory


biomechanics study using a repeated-measures,
counterbalanced design.

T OBJECTIVES: To compare patellofemoral joint


force and stress between a short- and long-step
forward lunge both with and without a stride.

T BACKGROUND: Although weight-bearing


forward-lunge exercises are frequently employed
during rehabilitation for individuals with patellofemoral joint syndrome, patellofemoral joint force
and stress and how they change with variations of
the lunge exercise are currently unknown.

T METHODS AND MEASURES: Eighteen


subjects used their 12-repetition maximum weight
while performing a short- and long-step forward
lunge both with and without a stride. Electromyography, ground reaction force, and kinematic variables were put into a biomechanical optimization
model, and patellofemoral joint force and stress
were calculated as a function of knee angle.
T RESULTS: Visual observation of the data show
that during the forward lunge, patellofemoral joint
force and stress increased progressively as knee
exion increased, and decreased progressively

as knee exion decreased. Between 70 and 90


of knee exion, patellofemoral joint force and
stress were signicantly greater when performing
a forward lunge with a short step compared to a
long step (P .025). Between 10 and 40 of knee
exion, patellofemoral joint force and stress were
signicantly greater when performing a forward
lunge with a stride compared to without a stride
(P .025).

T CONCLUSIONS: When the goal is to minimize


patellofemoral joint force and stress during the
forward lunge performed between 0 to 90
knee angles, it may be prudent to perform the
lunge with a long step compared to a short step,
and without a stride compared to with a stride,
because patellofemoral joint force and stress magnitudes were greater with a short step compared
to a long step at higher knee exion angles and
were greater with a stride compared to without a
stride at lower knee exion angles. J Orthop Sports
Phys Ther 2008;38(11):681-690. doi:10.2519/
jospt.2008.2694
T KEY WORDS: knee, knee kinetics, patella,
rehabilitation

patellofemoral
pain
syndrome
(PFPS).5,15,22,34,35 Forward lunges can be
performed with varying techniques, including variations in step length. In addition, forward lunges may or may not
incorporate the use of a stride. Lunging
without a stride involves keeping both
feet stationary throughout the knee-exing (descent) and knee-extending (ascent) lunging movements. Lunging with
a stride involves striding forward with the
lead lower extremity and either pushing
back to the starting position, or bringing
the trail lower extremity up to meet the
lead lower extremity (ie, a walking lunge).
A lunge with a longer step length typically
results in the lead knee being maintained
over the lead foot at the lowest position of
the lunge, while one with a shorter step
length typically results in the lead knee
translating anteriorly beyond the toes at
the lowest position of the lunge. Some clinicians believe that anterior translation
of the lead knee beyond the toes during
the forward lunge increases patellofemoral joint loading, but there is currently no
evidence to support this belief.
High patellofemoral joint force often
results in high patellofemoral joint stress
(patellofemoral force per unit patella
contact area), which may result in PFPS

1
Professor, Department of Physical Therapy, California State University, Sacramento, Sacramento, CA. 2 Assistant Professor, The Center for Biomedical Engineering, Department
of Mechanical Engineering and Engineering Science, University of North Carolina, Charlotte, NC. 3 Graduate Student (PhD), Department of Physical Therapy, Center for
Biomedical Engineering Research, University of Delaware, Newark, DE. 4 Graduate Student (PhD), Department of Kinesiology, Iowa State University, Ames, IA. 5 Associate
Professor, Kinesiology and Health Science Department, California State University, Sacramento, Sacramento, CA. 6 Smith and Nephew Chair of Research, American Sports
Medicine Institute, Birmingham, AL. 7 Vice President Education and Research, Champion Sports Medicine, Birmingham, AL. 8 Associate Professor, Orthopaedic Surgery, Duke
University Medical Center, Durham, NC. 9 Associate Professor, Kinesiology and Health Science Department, California State University, Sacramento, Sacramento, CA. 10 Medical
Director, American Sports Medicine Institute, Birmingham, AL; Medical Director, Andrews Institute, Gulf Breeze, FL. The protocol used in the current study was approved by
the Institutional Review Board at California State University, Sacramento. Please address correspondence to Dr Rafael Escamilla, Professor, Physical Therapy, California State
University, Sacramento, Department of Physical Therapy, 6000 J Street, Sacramento, CA 95819-6020. E-mail: rescamil@csus.edu

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 681

[
from numerous soft tissues, such as the
synovial plicae, infrapatellar fat pad, retinacula, joint capsule, and patellofemoral
ligaments.4 High patellofemoral joint
force can also elevate subchondral bone
stress in the patellofemoral joint. 3 Because the subchondral bone plate is rich
in pain receptors,36 increased subchondral bone stress may also result in PFPS.4
Patellofemoral joint stress can result in
cartilage degeneration and a decrease in
the ability of the cartilage to distribute
patellofemoral force.3 Therefore, understanding what patellofemoral force and
stress magnitudes are generated among
patellofemoral rehabilitation exercises
may be helpful to clinicians when prescribing therapeutic exercises to individuals with PFPS.
The goal of rehabilitation is to promote
muscle strengthening while minimizing
joint loading and pain. Understanding
how patellofemoral joint force and stress
vary among weight-bearing exercises
would allow athletes to better understand
the stress applied to this joint while performing various exercises. Moreover, it
would also allow clinicians to prescribe
and use these exercises in a safer and more
effective manner during rehabilitation of
individuals with various knee injuries, including those with PFPS. For example, if
lunging with a shorter step, with greater
anterior translation of the lead knee over
the toes, results in greater patellofemoral
joint force and stress compared to lunging with a longer step, with the lead knee
maintained over the foot, a shorter step
lunge may be discouraged during training
and rehabilitation. There may also be differences in patellofemoral joint force and
stress over a specic knee exion range of
motion between lunging with a short and
long step. Excess patellofemoral joint force
and stress over time may lead to PFPS in
individuals with asymptomatic patellofemoral joints, or may exacerbate PFPS
in patients with patellofemoral pathology
and delay the rehabilitation process.
Our purpose was to compare patellofemoral joint force and stress between a
forward lunge with a long and short step,

RESEARCH REPORT

performed with and without a stride.


Based on clinical observations, it was
hypothesized that patellofemoral joint
force and stress would be greater in the
forward lunge with a short step (forward
lunge short) compared to the forward
lunge with a long step (forward lunge
long), and would be greater with a stride
compared to without a stride.

METHODS
Subjects

ighteen healthy individuals (9


males and 9 females), without a history of patellofemoral pathology, with
a mean  SD age, mass, and height of 29
 7 y, 77  9 kg, and 177  6 cm, respectively, for males, and 25  2 y, 60  4 kg,
and 164  6 cm, respectively, for females,
participated. All subjects were required
to perform forward-lunge exercises pain
free and with proper form and technique
for 12 consecutive repetitions, using their
12-repetition maximum (12-RM) weight.
To help optimize the quality of the
electromyographic (EMG) signal, all participants had average or below-average
body fat, which was assessed by Baseline
skinfold calipers (model 68900; Country
Technology, Inc, Gays Mill, WI) and appropriate regression equations and body
fat standards set by the American College
of Sports Medicine.1 Mean  SD body fat
was 12%  4% for males and 18%  1%
for females. All subjects provided written
informed consent in accordance with the
Institutional Review Board at California
State University, Sacramento.

Exercise Description
Each subject performed the forward lunge
long (FIGURE 1) and forward lunge short
(FIGURE 2), with and without a stride. The
starting and ending positions of the forward lunge long with stride and forward
lunge short with stride were the same,
which involved standing upright with
both feet together. From this position, the
subject held a dumbbell weight in each
hand and lunged forward with the right
lower extremity towards a force platform

FIGURE 1. Forward lunge with a long step (forward


lunge long).

FIGURE 2. Forward lunge with a short step (forward


lunge short).

at ground level. At right foot contact, the


right knee slowly exed until maximum
right knee exion was obtained (approximately 90 to 100 during the forward lunge long and 100 to 110 during
the forward lunge short) as the left knee
made contact with the ground. From this
position the subject immediately pushed
backward off the force platform and returned to the upright standing position
with feet together. A metronome was used
to help ensure that the right knee exed
and extended at approximately 45/s.
The forward lunge long and short
without stride was performed the same

682 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

as the forward lunge long and short with


stride, with the exception that both feet
remained stationary throughout each
repetition during the forward lunge
long and short without stride. Specically, from the lowest position of the
forward lunge long and short shown in
FIGURES 1 and 2, the subject fully extended both knees then exed both knees,
returning back to the lowest position of
the lunge.
During the forward lunge long, each
subject used a step length that resulted in
the right leg (tibia) being approximately
vertical at the lowest position of the lunge
(FIGURE 1), thus maintaining the knee over
the foot. The mean  SD step length
(measured from left toe to right heel) for
the forward lunge long was 89  4 cm
for males and 79  6 cm for females. The
step length for the forward lunge short
was half the distance used for the forward
lunge long, causing the anterior surface
of the right knee to translate forward beyond the toes of the right foot (FIGURE 2).
During the forward lunge long and short,
with and without a stride, maximum
forward trunk tilt, which occurred near
maximum lead knee exion, was approximately 10 to 20 for all subjects.

Data Collection
Each subject attended a pretest session 1
week prior to testing. The experimental
protocol was reviewed, the subject was
given the opportunity to practice the
lunge variations, and each subjects step
length for the forward lunge long was determined. In addition, each subjects 12RM was determined while performing
the forward lunge with stride using a step
length halfway between the forward lunge
long and forward lunge short. This 12-RM
weight was used for the 4 lunge variations
during data collection. The mean  SD
total dumbbell mass used was 49  11 kg
for males and 32  8 kg for females.
Blue Sensor disposable surface electrodes (type M-00-S; Ambu Inc, Linthicum, MD) were used to collect EMG
data. These oval shaped electrodes (22
mm wide and 30 mm long) were placed

in a bipolar conguration along the longitudinal axis of each muscle, with a center-to-center distance of approximately
3 cm between electrodes. Prior to applying the electrodes, the skin was prepared
by shaving, abrading, and cleaning with
isopropyl alcohol wipes to reduce skin
impedance. Electrode pairs were then
placed on the subjects right side, using
previously described locations,2 for the
following muscles: (a) rectus femoris, (b)
vastus lateralis, (c) vastus medialis, (d)
medial hamstrings (semimembranosus
and semitendinosus), (e) lateral hamstrings (biceps femoris), and (f) gastrocnemius (middle portion between medial
and lateral bellies).
Spheres (3.8 cm in diameter) covered
with 3M reective tape were attached to
adhesives and positioned over the following bony landmarks: (a) third metatarsal head of the right foot, (b) medial and
lateral malleoli of the right leg, (c) upper
edges of the medial and lateral tibial plateaus of the right knee, (d) posterosuperior greater trochanters of the left and
right femurs, and (e) lateral acromion of
the right shoulder.
Once the electrodes and spheres were
positioned, the subject warmed up and
practiced the exercises as needed, and
data collection commenced. A 6-camera Peak Performance motion analysis
system (Vicon-Peak Performance Technologies, Inc, Englewood, CO) was used
to collect 60-Hz video data. Force data
were collected at 960 Hz using a force
platform (model OR6-6-2000; Advanced
Mechanical Technologies, Inc, Watertown, MA). EMG data were collected at
960 Hz using a Noraxon Myosystem unit
(Noraxon USA, Inc, Scottsdale, AZ). The
EMG amplier bandwidth frequency was
10 to 500 Hz, with an input impedance
of 20 000 k8, and the common-mode
rejection ratio was 130 dB. Video, EMG,
and force data were electronically synchronized and simultaneously collected
as each subject performed 1 set of 3 repetitions of the forward lunge long with
stride, forward lunge long without stride,
forward lunge short with stride, and for-

ward lunge short without stride, assigned


in a random order.
Subsequent to completing all lunge
variations, EMG data were collected during maximum voluntary isometric contractions (MVIC) to normalize the EMG
data collected during each lunge variation.
The MVIC for the rectus femoris, vastus
lateralis, and vastus medialis were collected in a seated position at 90 knee and hip
exion with a maximum-effort knee extension. The MVIC for the lateral and medial hamstrings was collected in the same
seated position, with a maximum-effort
knee exion. MVIC for the gastrocnemius
was collected during a maximum-effort
standing unilateral-stance toe raise, with
the ankle positioned approximately halfway between neutral and full plantar exion. Two 5-second trials were randomly
collected for each MVIC.

Data Reduction
Video images for each reective marker
were tracked and digitized in 3-dimensional space with Peak Performance
software, utilizing the direct linear transformation calibration method.27 Testing
of the accuracy of the calibration system
resulted in reective markers that could
be located in 3-dimensional space with
an error less than 0.7 cm. The raw position data were smoothed with a doublepass fourth-order Butterworth low-pass
lter with a cut-off frequency of 6 Hz.12
Joint angles, linear and angular velocities, and linear and angular accelerations
were calculated in a 2-dimensional sagittal plane of the knee utilizing appropriate
kinematic equations.12
Raw EMG signals were full-waved
rectied, smoothed with a 10-millisecond, moving-average window and linear
enveloped throughout the knee range of
motion for each repetition. These EMG
data were then normalized for each muscle and expressed as a percentage of each
subjects highest corresponding MVIC
trial. The MVIC was calculated using
the highest EMG signal over a 1-second
interval throughout the 5-second MVIC
trials. Normalized EMG data for the 3

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 683

Biomechanical Model
A previously described12,38 biomechanical
model of the knee was used to continuously calculate patellofemoral joint forces
throughout a 0-to-90 knee range of motion during the descent and ascent phases
of the lunge. Resultant force and torque
equilibrium equations were calculated
using inverse dynamics and the biomechanical knee model.12,38 Moment arms
of muscle forces and angles of the line of
action for muscles were represented as
polynomial functions of the knee exion
angle.16
Quadriceps, hamstrings, and gastrocnemius muscle forces were calculated
as previously described.12,38 Because the
accuracy of calculating muscle forces depends on accurate calculations of a muscles physiological cross-sectional area
(PCSA), maximum voluntary contraction
force per unit PCSA, and the EMG-force
relationship, resultant force and torque
equilibrium equations may not be satised. Therefore, each muscle force Fm(i)
was modied by the following equation
at each knee angle:
Fm(i) = ciklikviAiTm(i) [EMGi /MVICi ],
where Ai was PCSA of the ith muscle;
Tm(i) was MVIC force per unit PCSA of
the ith muscle; EMGi and MVICi were
EMG window averages of the ith muscle
EMG during exercise and MVIC trials;
ci was a weight factor (explained below),
adjusted in a computer optimization
program to minimize the difference between the resultant torque from the inverse dynamics (Tres) and the resultant
torque calculation from the biomechanical model (Tmi); kli represented each
muscles force-length relationship as
function of hip and knee angles (based
on muscle length, ber length, sarcomere length, pennation angle, and crosssectional area)32; and kvi represented

4000

Patellofemoral Force (N)

repetitions (trials) were then averaged at


corresponding knee angles between 0 to
90 and used in the biomechanical model
described below.

RESEARCH REPORT

3000

2000

1000

20

60

40

80

100

80

40

60

Descent

20

Ascent

Knee Angle ()
Forward lunge long with stride

Forward lunge short with stride

FIGURE 3. Mean  SD patellofemoral joint compressive force for the forward lunge long and short with stride.

10

Patellofemoral Stress (MPa)

0
0

20

60

40

80

100

80

40

60

Descent

20

Ascent

Knee Angle ()
Forward lunge long with stride

Forward lunge short with stride

FIGURE 4. Mean  SD patellofemoral joint stress for the forward lunge long and short with stride.

each muscles force-velocity relationship,


based on a Hill-type model for eccentric
and concentric muscle actions using the
following equations from Zajac37 and
Epstein and Herzog11:

the knee exors and 40 N/cm2 for the


quadriceps.7,20,21,33
The objective function used to determine each ith muscles coefficient ci was
as follows:
nm

kv = (b (a/F0 )v)/(b + v) concentric,


kv = C (C 1)(b + (a/F0)v)/(b v) eccentric,
with F0 representing isometric muscle force l0 muscle ber length at rest, v
velocity, a 0.32 F0, b 3.2 l0 per second,
and C 1.8. Forces generated by the knee
exors and extensors at MVIC were assumed to be linearly proportional to
their physiological cross-sectional area.
Muscle force per unit physiological crosssectional area at MVIC was 35 N/cm2 for

min f(ci) =

3 (1 c )

i=1

nm

+ M(Tres

3T

i=1

)2,

mi

subject to clowgcigchigh, where clow and


chigh were lower and upper limits for ci,
and M was a constant. The weight factor c was to adjust the nal muscle force
calculation. The bounds on c were set
between 0.5 and 1.5. The assumptions
associated with this model were that
knee torques from cruciate and collateral ligament forces and bony contact were assumed to be negligible, as
were forces and torques out of the sag-

684 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

= 0.99), which was used to determine contact areas for 70 knee angle (373 mm2),
80 knee angle (401 mm2), and 90 knee
angle (429 mm2). Like the current study,
a near-linear relationship between patellar contact area and knee angles has been
reported between 0 to 90 knee angles in
several studies involving weight-bearing
exercises.3,9,17,23,26

Patellofemoral Force (N)

4000

3000

2000

1000

20

60

40

100

80

80

40

60

Descent

20

Ascent

Knee Angle ()
Forward lunge long without stride

Forward lunge short without stride

FIGURE 5. Mean  SD patellofemoral joint compressive force for the forward lunge long and short without stride.

Patellofemoral Stress (MPa)

10

0
0

20

60

40

100

80

80

40

60

20

Ascent

Descent

Knee Angle ()
Forward lunge long without stride

Forward lunge short without stride

Data Analysis
A repeated-measures 2-way analysis of
variance (ANOVA), with step length (long
versus short) as 1 factor and stride (stride
versus no stride) as the second factor, was
used for each 10 angle (from 0 to 90)
during the descent phase and each 10
angle (from 90 to 0) during the ascent
phase. Bonferroni t tests were used to assess pairwise comparisons. To minimize
the probability of type I errors secondary
to the use of a separate ANOVA for each
knee angle, a Bonferroni adjustment was
performed with the level of signicance
established at 0.0025 (0.05/20 knee angles). A separate set of analyses was not
performed for patellofemoral joint stress
values because stress values for each knee
angle were derived from dividing force
data by a constant, therefore not affecting statistical results.

FIGURE 6. Mean  SD patellofemoral joint stress for the forward lunge long and short without stride.

RESULTS
ittal plane. Patellofemoral joint force
was a function of patellar tendon force
and quadriceps tendon force. Patellar tendon force was calculated by the
quadriceps tendon force and the ratio
of the patellar tendon force and the
quadriceps tendon force, as previously
described.29,30 The angles between the
patellar tendon, quadriceps tendon, and
patellofemoral joint were expressed as
functions of knee angle.29,30
Patellofemoral joint stress, which was
calculated every 10 between 0 to 90
knee angles, was expressed as the ratio
of patellofemoral joint force (calculated
from the biomechanical model described
above12,38) and patellar contact area. Patellar contact areas were determined for 10
intervals between 0 to 90 knee angles.

Contact areas from in vivo magnetic resonance imaging (MRI) data from Salsich et
al,26 who also used both male and female
subjects with healthy knees and had them
perform weight-bearing exercise using resistance, were employed for 0 (146 mm2),
20 (184 mm2), 40 (290 mm2), and 60
(347 mm2) knee angles. These 4 contact
area values formed a near linear relationship as a function of knee angle, resulting
in a line of best-t equation of y = 3.55x +
135 (r = 0.98), with y as contact area and
x as knee angle. This line of best-t equation was used to determine contact areas
for 10 knee angle (171 mm2), 30 knee
angle (242 mm2), and 50 knee angle (313
mm2). The contact areas for 40, 50, and
60 knee angles were used to develop the
line of best-t equation y = 2.81x + 176 (r

escriptive data for patellofemoral joint force and stress for each
lunge condition are provided in FIGURES 3 to 6. Visual observation of the data
indicate that patellofemoral joint force
and stress generally increased progressively as knee exion increased during
the descent phase and decreased progressively as knee exion decreased during
the ascent phase. Moreover, for a given
knee angle, patellofemoral joint force and
stress were generally similar between descent and ascent phases.
TABLES 1 and 2 provide patellofemoral
joint force and stress values during the descent and ascent phases, and as a function
of knee angle between the forward lunge
long and short conditions, and between

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 685

[
TABLE 1

RESEARCH REPORT

Patellofemoral Joint Force Values Between Forward-Lunge Step Length


Variations and Between Forward-Lunge Stride Variations*
Step Length Variations

Knee Angles

Long Step

Stride Variations

Short Step

P Value

With Stride

Without Stride

P Value

Descent phase
0

69  62

93  107

.255

106  81

62  52

.092

10

159  143

144  145

.100

212  154

97  55

.002

20

207  152

233  204

.222

306  230

147  63

.002

30

356  190

377  236

.966

440  261

298  126

.035

40

628  236

629  273

1.000

688  275

573  222

.024

50

1059  425

1051  382

.461

1106  443

1006  355

.292

60

1524  550

1660  514

.181

1601  557

1585  515

.960

70

1944  672

2335  759

.002

2121  831

2172  634

.625

80

2161  657

2836  889

.001

2450  929

2567  772

.287

90

2185  654

3039  853

.001

2588  935

2648  815

.328

90

2191  662

2860  786

.001

2505  804

2535  798

.702

80

2102  739

2768  839

.001

2416  895

2444  822

.868

70

1937  786

2365  807

.001

2214  935

2102  721

.478

60

1577  706

1839  728

.072

1839  859

1577  546

.086

50

1176  525

1298  567

.176

1395  653

1082  364

.013

40

780  344

829  360

.345

923  405

688  241

.002

30

504  240

500  217

.546

603  249

408  156

.001

20

312  180

287  137

.295

382  179

223  87

.001

10

168  119

149  83

.222

217  120

110  45

.001

66  46

81  65

.605

97  77

59  32

.041

Ascent phase

* Patellofemoral joint force values are mean  SD N. The mean values given for the 2 step length variations (long step and short step) were collapsed across the
2 stride variations (with stride and without stride), while the mean values given for the 2 stride variations were collapsed across the 2 step length variations.
The P values shown for step length variations and stride variations represent the main effects of the ANOVA.

Signicant difference (P .0025) between step length variations or stride variations.

the lunge with and without stride conditions. At 70, 80, and 90 knee angles
during both the descent and ascent phases, signicant main effects for lunge step
(long step versus short step) were found.
On average, the patellofemoral forces and
stresses were greater in the forward lunge
short compared to the forward lunge
long. At 10 and 20 knee angles of the
descent phase and at 40, 30, 20, and
10 knee angles of the ascent phase, signicant main effects for lunge stride (with
stride versus without stride) were found.
On average, patellofemoral joint forces
and stresses were signicantly greater in
the forward lunge with stride compared
to the forward lunge without stride.
There was only 1 angle at which a
significant interaction (P = .001) be-

tween step length variations and stride


variations was found. At 60 knee angle
during the descent phase, the forward
lunge short without stride generated
significantly greater patellofemoral
joint force compared to the forward
lunge long without stride, but there
was no significant difference in patellofemoral joint force between forward
lunge short with stride and forward
lunge long with stride.

DISCUSSION

s hypothesized, patellofemoral joint force and stress were both


greater while performing the forward lunge short, compared to the forward lunge long (but only at larger knee

angles), and were greater with a stride


compared to without a stride (but only at
smaller knee angles). When the goal is to
minimize patellofemoral joint force and
stress during the lunge, the forward lunge
long may be preferred compared to the
forward lunge short, and lunging without stride may be preferred compared to
lunging with a stride. The lack of signicant interactions implies that the effects
of long and short step variations are generally not affected by the use or absence
of a stride.
During the forward lunge short, it was
visually observed that the lead knee rst
began translating beyond the distal toes
at approximately 60 to 70 knee angles,
which is approximately when patellofemoral joint force and stress was initially

686 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

TABLE 2

Patellofemoral Joint Stress Values Between Forward-Lunge Step Length


Variations and Between Forward-Lunge Stride Variations*
Step Length Variations

Knee Angles

Long Step

Stride Variations

Short Step

P Value

With Stride

Without Stride

P Value

Descent phase
0

0.46  0.41

0.61  0.70

.255

0.70  0.76

0.40  0.34

.092

10

0.93  0.84

0.84  0.85

.100

1.24  1.08

0.57  0.33

.002

20

1.13  0.83

1.27  1.11

.222

1.66  1.25

0.80  0.34

.002

30

1.48  0.79

1.56  0.98

.966

1.82  1.08

1.24  0.52

.035

40

2.17  0.81

2.17  0.94

1.000

2.37  0.95

1.98  0.77

.024
.292

50

3.39  1.36

3.36  1.22

.461

3.54  1.42

3.22  1.14

60

4.39  1.58

4.78  1.48

.181

4.61  1.61

4.58  1.48

.960

70

5.22  1.80

6.21  2.04

.002

5.69  2.23

5.75  1.73

.625

80

5.39  1.64

7.08  2.22

.001

6.11  2.32

6.40  1.93

.287

90

5.09  1.53

7.09  1.99

.001

6.03  2.18

6.17  1.90

.328

90

5.11  1.54

6.67  1.83

.001

5.84  1.68

5.91  1.86

.702

80

5.24  1.84

6.91  2.09

.001

6.03  2.23

6.10  2.05

.868

70

5.20  2.11

6.32  2.17

.001

5.87  2.44

5.64  1.93

.478

60

4.54  2.04

5.30  2.10

.072

5.30  2.47

4.54  1.57

.086

50

3.76  1.68

4.15  1.82

.176

4.47  2.09

3.46  1.16

.013

40

2.69  1.19

2.89  1.24

.345

3.18  1.40

2.37  0.83

.002

30

2.09  0.99

2.07  0.90

.546

2.50  1.03

1.69  0.65

.001

20

1.70  0.98

1.56  0.75

.295

2.08  0.97

1.21  0.47

.001

10

0.99  0.70

0.88  0.49

.222

1.27  0.70

0.65  0.26

.001

0.43  0.30

0.53  0.43

.605

0.63  0.51

0.39  0.21

.041

Ascent phase

* Patellofemoral joint stress values are mean  SD MPa. The mean values given for the 2 step length variations (long step and short step) were collapsed across
the 2 stride variations (with stride and without stride), while the mean values given for the 2 stride variations were collapsed across the 2 length variations.
The P values shown for step length variations and stride variations represent the main effects of the ANOVA.

Signicant difference (P .0025) between step length variations or stride variations.

greater in the forward lunge short compared to the forward lunge long. During
the forward lunge short, the lead knee
continued translating beyond the toes as
the lead knee continued exing, translating 8  3 cm beyond the distal toes at
maximum lead knee exion. In contrast,
the lead knee did not translate beyond the
toes throughout the knee range of motion
during the forward lunge long. Because
signicantly greater patellofemoral joint
force and stress occurred between 70 to
90 knee angles during the forward lunge
short compared to the forward lunge long,
there appears to be a relationship between
anterior knee translation and increased
patellofemoral joint force and stress.
The primary cause of the greater patellofemoral joint force and stress between

70 to 90 knee angles during the descent


and ascent phases of the forward lunge
short compared to the forward lunge is
greater quadriceps force in the forward
lunge short at these knee angles. Between
70 to 90 knee angles during the descent
and ascent phases, the estimated mean
quadriceps forces (calculated from the
model) were approximately 20% to 30%
greater for the forward lunge short (approximately 600-650 N) compared to the
forward lunge long (approximately 450550 N), while the estimated mean hamstring forces (calculated from the model)
were approximately 25% to 35% greater
for the forward lunge long (approximately
60-110 N) compared to the forward lunge
short (approximately 40-90 N).
Using the forward lunge short may be

problematic for patients with PFPS, due


to increased patellofemoral joint force
and stress, especially at knee angles between 70 to 90. Our results support the
belief of many clinicians and trainers that
anterior lead knee translation beyond the
toes during the forward lunge may be
harmful to the patellofemoral joint and
should be avoided. The relationship between increased anterior knee translation
and increased patellofemoral joint force
and stress should be investigated during
other weight-bearing exercises, such as
the squat and leg press, because different
technique variations during weight-bearing exercise can result in lesser or greater
amounts of anterior knee translation.
Patellofemoral joint force and stress
curves were similar in shape to each other

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 687

[
due to near proportional increases in patellofemoral joint forces and patellar contact areas with increased knee exion. One
exception was at higher knee angles between 70 to 90, in which patellofemoral
joint stress began to plateau or decrease.
This occurred because, although patellar contact area increased nearly linearly
between 70 to 90, patellofemoral joint
force did not increase proportionally but,
instead, began to plateau. These ndings
are consistent with patellofemoral joint
force and stress data during the barbell
squat from Escamilla et al12 and Salem
and Powers.25 Escamilla et al12 reported
that patellofemoral joint forces increased
until 75 to 80 knee exion, and then
began to plateau or slightly decrease. Salem and Powers25 reported no signicant
differences in patellofemoral joint force
or stress at 75, 100, and 110 knee exion. Therefore, injury risk to the patellofemoral joint may not increase with knee
angles between 75 to 110 due to similar
magnitudes in patellofemoral joint stress
during these knee angles, with the benet
of increased quadriceps, hamstrings, and
gastrocnemius activity when training at
higher knee angles (75-110) compared
to lower knee angles (0-70).12
Because patellofemoral joint force
and stress both increased with knee
exion and decreased with knee extension (FIGURES 3-6), a more functional knee
exion range between 0 to 50 may be
appropriate during the early phases of
patellofemoral rehabilitation due to lower patellofemoral joint force and stress.
Higher knee angles between 60 to 90
may be more appropriate later in the rehabilitation process due to higher patellofemoral joint force and stress. This
same pattern of increased patellofemoral joint force and stress with increased
knee exion has been reported during the
squat and leg press.8,12,13,25,28,31
Peak patellofemoral joint force and
stress magnitudes from the current study
are less than some weight-bearing exercises, such as the squat and leg press,12 but
more than some weight-bearing functional
activities, such as walking14 and going up

RESEARCH REPORT
and down stairs.6 Escamilla et al12 reported
peak patellofemoral joint force and stress
magnitudes of 4500 to 4700 N and 11 to 12
MPa, respectively, at a 90 knee angle during the 12-RM squat and leg press. These
are approximately 50% greater than the
peak patellofemoral joint force and stress
magnitudes measured in the current study
during the forward lunge long and short.
Peak patellofemoral joint force and stress
in healthy subjects during fast walking are
reported to be approximately 900 N and
3.13 MPa, respectively,14 which are approximately 2 to 3 times lower than the
peak patellofemoral joint force and stress
magnitudes measured in the current study.
However, peak patellofemoral joint force
and stress magnitudes in healthy subjects
going up and down stairs are approximately 2500 N and 7 MPa, respectively,14 which
are similar to the peak patellofemoral joint
force and stress magnitudes measured in
the current study.
The greater patellofemoral joint force
and stress with a stride, as compared to
without a stride, between 10 to 20 during the descent and 10 to 40 during the
ascent, occurred, in part, because the estimated quadriceps forces were approximately 40% greater with a stride during
these knee angles, and patellofemoral
force is proportional to quadriceps force.
Quadriceps forces were greater with a
stride because peak ground reaction
forces acting on the lead foot, which generated a knee exor torque throughout
the lunge that was opposed by the knee
extensors, were approximately 15% to
20% greater with a stride, compared to
without a stride, during these knee angles.
Just after lead foot contact during the descent phase, when the knee was exed
10 to 20, ground reaction forces acting on the lead foot were greater with a
stride because the body had more forward
and downward acceleration compared to
without a stride. Therefore, with a stride,
the lead foot had to push harder into the
ground to slow down the forward and
downward accelerating body and control
the rate of lead knee exion. Between
10 to 40 during the ascent phase, peak

]
ground reaction forces were greater with
a stride, compared to without a stride, because the subject had to forcefully push
off the force platform to accelerate the
body backwards and upwards, and return
the body back to the upright starting position. Because lunging without a stride
resulted in both feet remaining stationary throughout the lunging motion, there
were minimal accelerations that occurred
during the descent and ascent phases.
Unfortunately, it is currently unknown
what patellofemoral joint force or stress
magnitudes, and over what duration, ultimately lead to patellofemoral pathology.
There are many factors that may contribute to patellofemoral pathology, such as
overuse or trauma, dysfunctional extensor
mechanism, weakness in the quadriceps
or hip external rotators, tight quadriceps,
hamstrings, or iliotibial band, lower extremity malalignment, and excessive rearfoot pronation. Nevertheless, clinicians can
use information regarding patellofemoral
joint force and stress magnitudes among
different weight-bearing exercises, technique variations, and functional activities
to make informed decisions regarding
which exercise they choose to employ during patellofemoral rehabilitation.
There are limitations in the current
study. Firstly, MRI knee kinematic data
have shown that during the weight-bearing squat the femur moves and rotates
underneath a relatively stationary patella, and that excessive femoral rotation
may increase patellofemoral joint stress
on the contralateral patellar facets.10,18,24
Unfortunately, there are no MRI knee
kinematic data for performing the lunge.
Therefore, it is unknown how much femoral rotation occurs during the lunge and
how this rotation varies among healthy
individuals and those with pathologies.
Another limitation is the effect of
Q-angle on patellofemoral joint force
and stress. From cadaveric data during
a simulated squat it was shown that an
increased Q-angle signicantly caused a
lateral shift and medial tilt and rotation
of the patella, which may increase patellofemoral joint stress.19 Unfortunately,

688 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

the amount of lateral shift and medial tilt


and rotation of the patella while performing the lunge is currently unknown.
Force from the hamstring muscles
acting on the leg may also affect patellofemoral joint force and stress, although
the hamstrings force magnitudes in the
current study were relatively low (generally less than 100 N). Cadaveric data have
demonstrated that increased hamstring
activity results in posterior translation of
the leg relative to the thigh; for any given
knee angle, this effect may result in a decrease in the angle formed between the
quadriceps force vector and the patellar
tendon force vector, increasing patellofemoral joint force and stress.18 Unfortunately,
the effect of hamstrings force on posterior
leg translation is currently unknown.
There are also limitations in the biomechanical model used in the current study.
Firstly, muscle and patellofemoral joint
forces were estimated from modeling techniques and not measured directly, which is
currently not possible in vivo in healthy subjects. However, using numerical boundaries between 0.5 and 1.5 for the term c in the
muscle force equation Fm(i) = ciklikviAiTm(i)
(EMGi/MVICi) resulted in the torques predicted by the EMG-driven model matching well (less than 2% differences), with the
torques generated from the inverse dynamics. The c term was used as a boundary for
adjusting each muscle force, and was determined by the optimization program for
each knee angle. The cost function had a
component to force c to be as close to 1.0
(optimal) as possible, making the model
more sensitive to the model parameters and
minimizing the amount of error.
Secondly, patellofemoral joint stress
magnitudes were measured using patellar contact area values from MRI data
from the literature and were not measured directly. However, the contact areas
used from the literature were determined
during loaded weight-bearing exercise in
healthy male and female subjects, similar
to the current study. Moreover, the near
linear and direct relationship between
contact area and knee angle has been
shown to be similar among studies.3,9,17,23,26

This implies that the patellofemoral joint


stress curve patterns shown in FIGURES 4
and 6 using contact areas from the literature will be similar to patellofemoral
joint stress curve patterns if contact areas
were measured directly using MRI. The
patellofemoral joint stress patterns are
important to clinicians in determining
what knee range of motions patellofemoral joint stress increases or decreases.
Thirdly, there are limitations regarding
the magnitude of patellofemoral contact
areas (and concomitant patellofemoral
joint stress magnitudes), in which the literature reports a wide array. For example,
both Patel et al23 and Besier et al,3 who
also used loaded weight-bearing exercise, reported approximately 40% to 50%
higher patellofemoral contact areas compared to contact areas data from Salsich
et al.26 Using these larger contact areas
from Patel et al23 and Besier et al3 would
result in smaller patellofemoral joint
stress magnitudes than those reported in
the current study. Differences in patellar
contact area magnitudes and concomitant patellofemoral joint stress magnitudes among weight-bearing studies are
due to many factors, such as sex (greater
in males than females), mass (greater in
larger individuals), measuring techniques,
and loading magnitudes (greater loading
and quadriceps contraction results in increased contact areas).3,26 Nevertheless,
although patellofemoral joint stress magnitudes during weight-bearing activities
in the current study and throughout the
literature are approximations only, these
varying magnitudes may be helpful to clinicians in deciding interventions to employ during patellofemoral rehabilitation.
Finally, the current study was limited
to healthy subjects who were able to perform the forward lunge in the sagittal
plane of motion without transverse and
frontal plane motions. Future studies are
needed during the forward lunge and
other weight-bearing exercises to investigate the effects of transverse plane rotary
motions and frontal plane valgus/varus
motions on patellofemoral joint force and
stress magnitudes, which may occur with

individuals with patellofemoral pathology. Additional studies are also needed


using other lunge technique variations,
such as lunging up to a step or using a
step length somewhere between the forward lunge long and forward lunge short,
which may help determine an optimal
step length or step height for minimizing
patellofemoral joint force and stress.

CONCLUSIONS

rom visual observation, patellofemoral joint force and stress magnitudes were generally greater at
higher knee angles and smaller at lower
knee angles; but, for a given knee angle,
patellofemoral joint stress magnitudes
were generally similar between descent
and ascent phases. Patellofemoral joint
force and stress magnitudes were greater
during the forward lunge short compared
to the forward lunge long at 70, 80, and
90 knee angles during both descent and
ascent phases, and were greater with a
stride compared to without a stride at
10 and 20 knee angles of the descent
phase and at 40, 30, 20, and 10 knee
angles of the ascent phase. When the goal
is to minimize patellofemoral joint force
and stress during the forward lunge performed between 0 to 90 knee angles,
it may be prudent to perform the lunge
with a long step compared to a short step,
and without a stride compared to with a
stride, because patellofemoral joint force
and stress magnitudes were greater with
a short step compared to a long step at
higher knee exion angles and were
greater with a stride compared to without
a stride at lower knee exion angles. T

ACKNOWLEDGEMENTS: The efforts of Dr Bonnie

Raingruber and funding from the National


Institute of Child Health and Human Developments Extramural Associates Research
Development Award program made this research possible. Also acknowledged are Lisa
Bonacci, Toni Burnham, Juliann Busch,
Kristen DAnna, Pete Eliopoulos, and Ryan
Mowbray for their assistance in data collection and analyses.

journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 689

[
KEY POINTS
FINDINGS: Patellofemoral joint force and

stress magnitudes were greater during


the forward lunge short compared to the
forward lunge long at higher knee angles
and were greater with a stride compared
to without a stride at lower knee angles.
IMPLICATION: Our findings can be used to
help guide patellofemoral rehabilitation
regarding the selection of forward lunge
techniques.
CAUTION: Although the torques predicted
by the EMG driven model were only 1%
to 2% different compared to the torques
generated from the inverse dynamics,
it should be emphasized that muscle
and patellofemoral joint forces were
estimated from the modeling techniques
and not measured directly.

REFERENCES
1. Balady G, Berra K, Golding L. ACSMs Guidelines
for Exercise Testing and Prescription. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000.
2. Basmajian JV, Blumenstein R. Electrode Placement in EMG Biofeedback. Baltimore, MD: Williams & Wilkins; 1980.
3. Besier TF, Draper CE, Gold GE, Beaupre GS,
Delp SL. Patellofemoral joint contact area
increases with knee exion and weight-bearing.
J Orthop Res. 2005;23:345-350. http://dx.doi.
org/10.1016/j.orthres.2004.08.003
4. Biedert RM, Sanchis-Alfonso V. Sources of anterior
knee pain. Clin Sports Med. 2002;21:335-347, vii.
5. Boling MC, Bolgla LA, Mattacola CG, Uhl TL,
Hosey RG. Outcomes of a weight-bearing
rehabilitation program for patients diagnosed
with patellofemoral pain syndrome. Arch Phys
Med Rehabil. 2006;87:1428-1435. http://dx.doi.
org/10.1016/j.apmr.2006.07.264
6. Brechter JH, Powers CM. Patellofemoral joint
stress during stair ascent and descent in persons with and without patellofemoral pain. Gait
Posture. 2002;16:115-123.
7. Cholewicki J, McGill SM, Norman RW. Comparison of muscle forces and joint load from an optimization and EMG assisted lumbar spine model:
towards development of a hybrid approach. J
Biomech. 1995;28:321-331.
8. Cohen ZA, Henry JH, McCarthy DM, Mow VC,
Ateshian GA. Computer simulations of patellofemoral joint surgery. Patient-specic models for tuberosity transfer. Am J Sports Med. 2003;31:87-98.
9. Cohen ZA, Roglic H, Grelsamer RP, et al. Patellofemoral stresses during open and closed kinetic chain exercises. An analysis using computer
simulation. Am J Sports Med. 2001;29:480-487.

RESEARCH REPORT
10. Doucette SA, Child DD. The effect of open and
closed chain exercise and knee joint position
on patellar tracking in lateral patellar compression syndrome. J Orthop Sports Phys Ther.
1996;23:104-110.
11. Epstein M, Herzog W. Theoretical Models of Skeletal Muscle: Biological and Mathematical Considerations. New York, NY: John Wiley & Sons; 1998.
12. Escamilla RF, Fleisig GS, Zheng N, Barrentine
SW, Wilk KE, Andrews JR. Biomechanics of
the knee during closed kinetic chain and open
kinetic chain exercises. Med Sci Sports Exerc.
1998;30:556-569.
13. Escamilla RF, Fleisig GS, Zheng N, et al. Effects
of technique variations on knee biomechanics
during the squat and leg press. Med Sci Sports
Exerc. 2001;33:1552-1566.
14. Heino Brechter J, Powers CM. Patellofemoral
stress during walking in persons with and
without patellofemoral pain. Med Sci Sports
Exerc. 2002;34:1582-1593. http://dx.doi.
org/10.1249/01.MSS.0000035990.28354.c6
15. Heintjes E, Berger MY, Bierma-Zeinstra SM,
Bernsen RM, Verhaar JA, Koes BW. Exercise
therapy for patellofemoral pain syndrome.
Cochrane Database Syst Rev. 2003;CD003472.
http://dx.doi.org/10.1002/14651858.CD003472
16. Herzog W, Read LJ. Lines of action and moment
arms of the major force-carrying structures
crossing the human knee joint. J Anat. 1993;182
( Pt 2):213-230.
17. Hinterwimmer S, Gotthardt M, von EisenhartRothe R, et al. In vivo contact areas of the knee
in patients with patellar subluxation. J Biomech.
2005;38:2095-2101. http://dx.doi.org/10.1016/j.
jbiomech.2004.09.008
18. Li G, DeFrate LE, Zayontz S, Park SE, Gill TJ. The
effect of tibiofemoral joint kinematics on patellofemoral contact pressures under simulated
muscle loads. J Orthop Res. 2004;22:801-806.
http://dx.doi.org/10.1016/j.orthres.2003.11.011
19. Mizuno Y, Kumagai M, Mattessich SM, et
al. Q-angle inuences tibiofemoral and
patellofemoral kinematics. J Orthop Res.
2001;19:834-840. http://dx.doi.org/10.1016/
S0736-0266(01)00008-0
20. Narici MV, Landoni L, Minetti AE. Assessment
of human knee extensor muscles stress from
in vivo physiological cross-sectional area and
strength measurements. Eur J Appl Physiol Occup Physiol. 1992;65:438-444.
21. Narici MV, Roi GS, Landoni L. Force of knee
extensor and exor muscles and cross-sectional
area determined by nuclear magnetic resonance
imaging. Eur J Appl Physiol Occup Physiol.
1988;57:39-44.
22. Natri A, Kannus P, Jarvinen M. Which factors
predict the long-term outcome in chronic
patellofemoral pain syndrome? A 7-yr prospective follow-up study. Med Sci Sports Exerc.
1998;30:1572-1577.
23. Patel VV, Hall K, Ries M, et al. Magnetic resonance imaging of patellofemoral kinematics with
weight-bearing. J Bone Joint Surg Am. 2003;85A:2419-2424.

]
24. Powers CM. The inuence of altered lowerextremity kinematics on patellofemoral joint
dysfunction: a theoretical perspective. J Orthop
Sports Phys Ther. 2003;33:639-646.
25. Salem GJ, Powers CM. Patellofemoral
joint kinetics during squatting in collegiate
women athletes. Clin Biomech (Bristol, Avon).
2001;16:424-430.
26. Salsich GB, Ward SR, Terk MR, Powers CM. In
vivo assessment of patellofemoral joint contact
area in individuals who are pain free. Clin
Orthop Relat Res. 2003;277-284. http://dx.doi.
org/10.1097/01.blo.0000093024.56370.79
27. Shapiro R. Direct linear transformation method
for three-dimensional cinematography. Res Q.
1978;49:197-205.
28. Steinkamp LA, Dillingham MF, Markel MD, Hill
JA, Kaufman KR. Biomechanical considerations
in patellofemoral joint rehabilitation. Am J
Sports Med. 1993;21:438-444.
29. van Eijden TM, Kouwenhoven E, Verburg J, Weijs
WA. A mathematical model of the patellofemoral
joint. J Biomech. 1986;19:219-229.
30. van Eijden TM, Kouwenhoven E, Weijs WA.
Mechanics of the patellar articulation. Effects of patellar ligament length studied with
a mathematical model. Acta Orthop Scand.
1987;58:560-566.
31. Wallace DA, Salem GJ, Salinas R, Powers CM.
Patellofemoral joint kinetics while squatting with
and without an external load. J Orthop Sports
Phys Ther. 2002;32:141-148.
32. Wickiewicz TL, Roy RR, Powell PL, Edgerton VR.
Muscle architecture of the human lower limb.
Clin Orthop Relat Res. 1983;275-283.
33. Wickiewicz TL, Roy RR, Powell PL, Perrine JJ,
Edgerton VR. Muscle architecture and forcevelocity relationships in humans. J Appl Physiol.
1984;57:435-443.
34. Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D. Open versus closed
kinetic chain exercises in patellofemoral pain:
a 5-year prospective randomized study. Am J
Sports Med. 2004;32:1122-1130. http://dx.doi.
org/10.1177/0363546503262187
35. Witvrouw E, Lysens R, Bellemans J, Peers K,
Vanderstraeten G. Open versus closed kinetic
chain exercises for patellofemoral pain. A prospective, randomized study. Am J Sports Med.
2000; 28: 687-694.
36. Wojtys EM, Beaman DN, Glover RA, Janda D. Innervation of the human knee joint by substanceP bers. Arthroscopy. 1990;6:254-263.
37. Zajac FE. Muscle and tendon: properties, models,
scaling, and application to biomechanics and motor control. Crit Rev Biomed Eng. 1989;17:359-411.
38. Zheng N, Fleisig GS, Escamilla RF, Barrentine
SW. An analytical model of the knee for estimation of internal forces during exercise. J Biomech. 1998;31:963-967.

690 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy

MORE INFORMATION
WWW.JOSPT.ORG