THEKNE-02537; No of Pages 8

The Knee xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

The Knee

The effect of knee flexor and extensor fatigue on shock absorption during
cutting movements after a jump landing
Youkyung Kim a, Changhong Youm a,b,⁎, Minji Son a, Jinhee Kim a, Myeounggon Lee a
a
Biomechanics Laboratory, College of Health Sciences, Dong-A University, Busan, Republic of Korea
b
Department of Health Care and Science, College of Health Sciences, Dong-A University, Busan, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: Sporting situations include instances of continuous and/or integrated movements.
Received 29 January 2016
However, the effect of fatigue on the performance of these movements remains unclear.
Received in revised form 4 September 2017
Purpose: To investigate the effect of knee flexor and extensor fatigue on the shock absorption
Accepted 20 September 2017
Available online xxxx strategy of the lower limb during cutting movements performed after jump landings.
Methods: Twenty-four healthy participants performed cutting movements following jump landings
from two heights – 30 cm and 40 cm – and under three levels of lower limb fatigue: pre-fatigue
Keywords:
(100% peak knee extension torque), and post-fatigue 50% (post-50%) and 30% (post-30%) peak
Kinematics
Kinetics
knee extension torque. Fatigue was induced by repeated isokinetic flexion/extension of the knee
Knee fatigue (60°/s).
Shock absorption Results: Compared to the pre-fatigue condition, power and work at the knee joint decreased under
Side cutting both post-50% and post-30% conditions (P b 0.001), while the work performed by the ankle
Single-leg landing (P b 0.001) increased significantly. An increase in height from 30 cm to 40 cm was associated
with an increase in the range of motion of the ankle (P b 0.001) and knee (P = 0.022), peak ver-
tical ground reaction force (P b 0.001), rate of loading (P b 0.001), knee stiffness (P = 0.026) and
peak power of the knee (P b 0.001), as well as the work performed by the knee (P b 0.001) and
hip (P b 0.001) joints.
Conclusions: Under substantial muscle fatigue the proportion of shock absorption contributed
by the knee for cutting movements performed after jump landings from a height of 40 cm
decreased; there was an adaptive increase in the contribution by the ankle.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction

Fatigue is commonly experienced during dynamic physical and daily activities [1,2]. Functionally, fatigue is defined as a reduction
in maximum force production and power output, loss of exercise capacity, decreased reaction time, and an over-perception of the
force generated during repeated muscle contraction [3,4]. It has been proposed that fatigue also alters the biomechanical and neuro-
muscular factors associated with the risk of sustaining a musculoskeletal injury [5–7]. Therefore, researchers have considered fatigue
in their evaluation of injury mechanisms related to sport.
Fatigue has been investigated as a predisposing factor for injury in sports in general [8]. Specifically for landing activities
(including jumping down from a height, a drop jump, and hopping) researchers have evaluated the effect of lower limb muscle

⁎ Corresponding author at: Department of Health Care and Science, College of Health Sciences, Dong-A University, 37 Nakdong-Daero 550beon-gil, Saha-gu, Busan
49315, Republic of Korea.
E-mail address: chyoum@dau.ac.kr (C. Youm).

https://doi.org/10.1016/j.knee.2017.09.007
0968-0160/© 2017 Elsevier B.V. All rights reserved.

Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007
2 Y. Kim et al. / The Knee xxx (2017) xxx–xxx

fatigue on the mechanics of landing activities using both general [9,10–14], and local muscle fatigue protocols [5,7,15–17]. General
fatigue involves multiple joints and muscle groups, whereas local fatigue is induced at muscles that are specifically relevant to a
joint or injury mechanism under investigation [10,18]. Within the context of landing from a jump, local fatigue has been induced
using repeated cycles of isokinetic knee extension and flexion at angular velocities of 120–180°/s. The effects of fatigue at the knee
joint have subsequently been evaluated using different landing tasks (drop landing, jump landing or hopping) performed from
heights varying between 25.4 and 50 cm, at torque values for the target muscle group of 25–50% of peak torque measured at
rest [5,7,15,17].
However, the effects of two different levels of general lower limb fatigue on lower limb shock absorption strategies during landing
and cutting tasks have not been investigated. Therefore, the purpose of the current study was to investigate the effect of knee flexor
and extensor fatigue on the shock absorption strategy of the lower limb during cutting movements performed after jump landings. It
was hypothesized that the effects of decreased peak knee torque on the shock absorption strategy would be modulated by the height
of the jump.

2. Methods

2.1. Participants

Twenty-four participants were recruited among physical education students at the current university. The study group included
13 females (age 20.77 ± 1.01 years; height 165.62 ± 6.51 cm; and mass 58.76 ± 6.58 kg) and 11 males (age 21.27 ± 2.24 years;
height 179.68 ± 4.79 cm; and mass 72.20 ± 7.19 kg). All participants regularly performed recreational activities and sport at least
three times per week. Participants had no history of orthopedic or neurologic disorder of the lower limb within the 6 months preced-
ing data collection. All participants provided informed consent, and the study was approved by the Institutional Review Board of
Dong-A University.

2.2. Instrumentation

Nine infrared cameras (Vicon MX-T10, Oxford Metrics, Oxford, UK) and one force plate (AMTI OR6-7, Watertown, MA, US) were
used to combine motion capture with ground reaction force (GRF) data. The GRF system (1200 Hz) was synchronized to the motion
capture system (120 Hz) using the Nexus software. Motion data were low-pass filtered, using a second-order Butterworth filter with a
cut-off frequency of 6 Hz, and analog force data filtered at 25 Hz [8,19,20].
Based on a customized version of the Vicon Plug-in Gait marker set [19,21], retroreflective markers (14-mm spherical type) were
attached on the following anatomical landmarks: the clavicle, sternum, seventh cervical vertebra, tenth thoracic vertebra, and bilaterally
on the front and back of the head, shoulder, lower third of the upper arm, lateral humeral epicondyle, lower third of the forearm, medial

Figure 1. A schematic diagram of the fatigue protocol.

Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007
 Y. Kim et al. / The Knee xxx (2017) xxx–xxx 3

and lateral wrist styloid processes, third metacarpal head, anterior superior iliac spine, posterior superior iliac spine, lower one-third of
the lateral thigh, lateral femoral epicondyle, lower one-third of the lateral shank, calcaneus, lateral malleolus, and second metatarsal
head (Appendix A). To reduce motion artifacts, all markers were secured with double-sided tape and athletic tape.

2.3. Procedure

Participants performed three testing sessions at a one-week interval to control for cumulative effects of fatigue. During the first
testing session, participants' age, height, body weight, knee width, ankle width, leg length, and distance between the anterior
superior iliac crests were measured, and the maximum knee extension torque was determined by isokinetic dynamometry
(Cybex, HUMACNORM, CSMI, USA). Prior to testing, participants completed a warm-up, including stretching and cycling for
10 min, with a three-minute rest provided before assessment of the isokinetic peak knee extension torque. For testing, partici-
pants were seated in an upright posture, with the hips flexed to 90°, and stabilized using a four-point restraining system,
which included a belt across the pelvis. Peak knee extension torque was defined as the greatest torque achieved during five
successive maximal concentric knee extensions, performed from 90° of knee flexion to 0° of knee extension, and at a movement
velocity of 60°/s (Figure 1). Verbal encouragement and visual feedback of torque output were provided to maximize effort.
The maximum knee extension torque was then used to set the target reference levels for fatigue on subsequent testing
sessions. Use of the equipment and all study procedures were explained to participants at this first visit, and participants were
provided with an opportunity to practice the cutting movements after jump landing, and the contractions used for the fatiguing
protocol.
During the second testing session, all participants wore a Spandex shirt, shorts and no shoes, and completed a 10-minute
warm-up before the testing procedure. With respect to the landing protocol, participants performed five jump landings from a
30-cm-high box onto the force plate. Participants were instructed to land on their dominant lower limb, followed by a side
step in a 45° direction using their non-dominant lower limb. The dominant lower limb was identified using self-reported answers
and a ball-kicking test [5]. Participants were asked to keep their arms in an extended position behind their back during the jump,
to eliminate the contribution of the upper limbs to the landing strategy. For the fatigue protocol, participants performed isokinetic
flexion/extension of the knee joint exercise through a range from 0° (extension) to 90° of knee flexion at an angular velocity
of 60°/s. The fatigue protocol was terminated when the peak torque of knee extension was b50% and b30% on three or more
consecutive repetitions (Figure 1) [5,17].
The cutting movement following landing from the jump was performed prior to the fatigue protocol, and at post-50% and
post-30% fatigue levels of the maximum knee extension torque (Figure 2). When the first fatigue protocol ended, participants
immediately moved from the dynamometer to perform the jumping task (within two minutes) to reduce the effect of recovery
from muscular fatigue. During the tests, participants received standardized verbal instructions to maintain maximal effort. At
the third testing session, participants performed the landing and fatigue protocols, utilizing the same procedures as in the second
session, but jumping from a height of 40 cm.

2.4. Data analysis

Data analysis was performed with Nexus software (Vicon) and Matlab 8.0 (Mathworks, Sherborn, MA, USA). For analysis,
averages of five successful landings prior to fatigue and at each of the two levels of fatigue for the two heights were calculated.
The landing phase, from which all outcomes variables were quantified, was defined as the time from the initial contact with the
ground (threshold value on the force plate of 10 N) to maximum knee flexion angle [8,22].

Figure 2. A schematic diagram of the landing and fatigue protocol procedure. Participants performed the five cutting movements following jump landing from a
30-cm high box prior to the fatigue protocol, and at post-50% and post-30% fatigue levels of the maximum knee extension torque. A second session was held
1 week later, using the same procedures but using a 40-cm high landing.

Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007
4 Y. Kim et al. / The Knee xxx (2017) xxx–xxx

The joint range of motion (ROM) of the lower extremity joints, the peak vertical ground reaction force (PVGRF), the rate of loading
of the lower extremity, knee stiffness, peak knee power, and lower limb energy dissipation (eccentric work) were calculated over this
phase. The joint ROM was calculated as the difference between the joint angle at initial contact and the joint angle at maximum knee
flexion. Positive sagittal plane joint ROMs were hip flexion, knee flexion and ankle dorsiflexion. Peak VGRF was normalized to body
mass. Rate of loading was calculated as the normalized PVGRF divided by the time from initial contact to PVGRF [23]. Knee stiffness
was calculated as the change in normalized net moment (Nm) divided by the change in angular displacement of knee (°), from initial
contact to peak knee flexion (Nm/kg/°) [24–27]. Peak knee power was defined as the product of knee angular velocity and moment.
The eccentric work values for the hip, knee and ankle joints were calculated as the integral of joint power over time, whereby negative
(eccentric) work represented energy dissipation by the joint muscles [28]. All kinetic and kinematic variables were normalized to
body mass.

2.5. Statistical analyses

All statistical analyses were performed using SPSS (version 21.0, SPSS Inc., Chicago, IL). Descriptive statistical analysis, mean ± stan-
dard deviation, was used to describe the characteristics of each variable. After confirmation of normality using the Shapiro–Wilk test,
a 2 × 3 repeated measures two-way analysis of variance (ANOVA) was used to evaluate main effects and interactions of the three
fatigue levels (pre, post-50%, and post-30%) and two heights (30 cm and 40 cm). For the post-hoc analysis, difference between fatigue
levels was evaluated using a one-way analysis of variance (ANOVA), with the P-value adjusted for multiple comparisons, using the
Bonferroni method, to 0.0167 (0.05/3). Differences between the two landing heights (30 cm and 40 cm) were evaluated using a
paired sample t-test analysis, with a P-value 0.05 being significant.

3. Results

The effects of the height of the jump, across all three fatigue levels, are shown in Figures 3 and 4, and reported in Tables 1 and 2.
Ankle ROM (pre, post-50%, post-30%: P b 0.001; Figure 3), knee ROM (pre-, post-50%: P b 0.001, post-30%: 0.022; Figure 3), PVGRF
(pre-, post-50%, post-30%: P b 0.001; Table 1), rate of loading (pre, post-50%, post-30%: P b 0.001; Table 1), peak knee power (pre,
post-50%, post-30%: P b 0.001; Table 1), and eccentric work performed by the knee (pre: P = 0.001, post-50%, post-30%: P b 0.001;
Figure 4) were significantly greater at the 40-cm than 30-cm height at all three fatigue levels. Additionally, at the 40-cm height,

Figure 3. Ankle, knee, and hip ROM at pre, post-50%, and post-30% fatigue levels, during the landing phase, from 30-cm and 40-cm heights. *Significant difference between
fatigue levels at both heights (P b 0.05) # Significant difference between heights (P b 0.05).

Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007
 Y. Kim et al. / The Knee xxx (2017) xxx–xxx 5

Figure 4. Eccentric work performed by the ankle, knee, and hip at pre, post-50%, and post-30% fatigue levels, during the landing phase, from 30-cm and 40-cm
heights. *Significant difference between fatigue levels at both heights (P b 0.05) #Significant difference between heights (P b 0.05).

time to PVGRF (pre: P = 0.005, post-50%: P = 0.009, post-30%: P = 0.001; Table 1) was faster, and ankle stiffness (pre, post-50%:
P b 0.001, post-30%: P = 0.001; Table 2) was lower than at the 30 cm height at all three fatigue levels. Knee stiffness (post-50%:
P = 0.036, post-30%: P = 0.026; Table 2) and eccentric work performed by the hip (post-50%: P = 0.006, post-30%:
P b 0.001; Figure 4) were significantly greater at the 40-cm than 30-cm height at post-50% and post-30% fatigue.
Compared to the pre-fatigue state, the post-30% and post-50% fatigue conditions were associated with a significant increase in
the ROM of the ankle joint (30 cm: P b 0.001, 40 cm: P = 0.001; Figure 3), decrease in the ROM of the knee, at post-30% only
(40 cm: P = 0.001; Figure 3), slower time to PVGRF (30 cm: P b 0.001, 40 cm: P = 0.001; Table 1) and lower rate of loading
(30 cm, 40 cm: P b 0.001; Table 1). Increasing fatigue for the 30-cm and 40-cm height was associated with a decrease in peak
negative (eccentric) power at the knee (pre- N post-50% N post-30%, P b 0.001; Table 1), associated with an increase in eccentric
work at the ankle (pre- b post-50% b post-30%, P b 0.001; Figure 4). For the 30-cm height, the eccentric work performed by the
knee also decreased (pre- N post-50% N post-30%, P b 0.001; Figure 4), but with the work performed at the post-30% fatigue level
still being smaller than at the pre-fatigue level for jumps from the 40-cm height (P = 0.006; Figure 4). The ROM and work values
for the hip, knee and ankle at the two jump heights and three fatigue levels are summarized in Appendices B and C.

Table 1
Peak VGRF, time to peak VGRF, rate of loading, peak power of the knee during the landing phase.

Pre Post-50% Post-30% Pa Post-hoc

Peak VGRF 30 cm 26.95 ± 1.88 26.34 ± 1.92 26.61 ± 2.06 (H) 0.000 -
(N/kg) 40 cm 28.40 ± 1.94 27.75 ± 2.22 28.17 ± 1.78 (F) 0.023 -
Pb 0.000 0.000 0.000 (H × F) 0.868
Time to peak 30 cm 0.13 ± 0.02 0.14 ± 0.02 0.14 ± 0.02 (H) 0.000 3,2 N 1
VGRF (s) 40 cm 0.12 ± 0.02 0.13 ± 0.02 0.13 ± 0.02 (F) 0.000 3,2 N 1
Pb 0.005 0.009 0.001 (H × F) 0.249
Rate of loading 30 cm 211.28 ± 34.36 195.98 ± 28.95 189.50 ± 25.10 (H) 0.000 1 N 2,3
(N/kg/s) 40 cm 241.11 ± 42.09 217.12 ± 32.84 220.67 ± 36.20 (F) 0.000 1 N 3,2
Pb 0.000 0.000 0.000 (H × F) 0.101
Peak power of 30 cm −11.13 ± 3.23 −9.79 ± 3.36 −8.91 ± 2.76 (H) 0.000 1N2N3
the knee (W/kg) 40 cm −17.24 ± 5.18 −14.87 ± 4.66 −13.68 ± 4.81 (F) 0.000 1N2N3
Pb 0.000 0.000 0.000 (H × F) 0.069

All data are given as mean ± standard deviations.

P a is derived from two-way ANOVA with repeated measures between landing heights (H) and fatigue levels (F).
P b is derived from paired t-tests for the 30-cm and 40-cm heights.
Post-hoc is derived from Bonferroni correction within pre (1), post-50% (2), and post-30% (3) groups.

Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007
6 Y. Kim et al. / The Knee xxx (2017) xxx–xxx

Table 2
Stiffness of ankle, knee, hip joint during the landing phase.

Pre Post-50% Post-30% Pa Post-hoc

Ankle stiffness 30 cm 0.06 ± 0.01 0.05 ± 0.01 0.06 ± 0.01. (H) 0.000 –
(Nm/kg/deg) 40 cm 0.04 ± 0.01 0.04 ± 0.01 0.05 ± 0.01 (F) 0.383 –
Pb 0.000 0.000 0.001 (H × F) 0.562
Knee stiffness 30 cm 0.04 ± 0.02 0.04 ± 0.02 0.04 ± 0.02 (H) 0.039 –
(Nm/kg/deg) 40 cm 0.04 ± 0.02 0.05 ± 0.02 0.05 ± 0.02 (F) 0.204 –
Pb 0.228 0.036 0.026 (H × F) 0.472
Hip stiffness 30 cm 0.05 ± 0.04 0.07 ± 0.06 0.06 ± 0.06 (H) 0.405 –
(Nm/kg/deg) 40 cm 0.07 ± 0.05 0.08 ± 0.06 0.06 ± 0.04 (F) 0.245 –
Pb 0.073 0.517 0.590 (H × F) 0.100

All data are given as mean ± standard deviations.

Pa is derived from two-way ANOVA with repeated measures between landing heights (H) and fatigue levels (F).
Pb is derived from paired t-tests for the 30-cm and 40-cm heights.
Post-hoc is derived from Bonferroni correction within pre (1), post-50% (2), and post-30% (3) groups.

4. Discussion

The current study identified a main effect of post-50% and post-30% fatigue on peak power at the knee joint and the magnitude of
eccentric work performed by the ankle and knee. It also identified a main effect of landing height on the ROM of the ankle and knee,
PVGRF, time to PVGRF, rate of loading, peak knee power, stiffness of the knee and ankle, and the eccentric work performed by the knee
and hip.

4.1. Lower extremity kinematics and kinetics for fatigue levels

The decrease in knee ROM during the landing post-fatigue agrees with previously reported findings [15,17]. The range of knee
flexion during landing plays a key role in absorbing shock [5,19], negatively correlating with PVGRF [19]. As such, an increase in
the range of knee flexion post-landing decreases the risk of injury to the anterior cruciate ligament (ACL) during landing [13,17].
The decrease in knee ROM from post-50% to post-30% indicates that greater fatigue may reduce the ability of the knee to absorb
shock, which would increase the risk of ACL injury during landing. In the current study, at the post-30% fatigue level, the decrease
in knee ROM was associated with a decrease in the negative (eccentric) peak power of the knee. This decreased contribution
to shock absorption by the knee was compensated by the ankle joint, with identified increases in ROM and eccentric work. Therefore,
for complex movements such as cutting after a jump landing, substantial fatigue may compromise the shock absorption capacity of
the knee, which would increase the risk of injury to both the knee and ankle joints. In contrast to the current findings, Coventry
et al. reported that as ankle ROM decreased during landing from a jump, the VGRF decreased, with a corresponding decrease in
the eccentric work performed at the ankle and increase in the contribution of eccentric work performed at the hip [14]. For landings
performed after muscle fatigue, Madigan and Pidcoe reported a decrease in the VGRF and ankle flexor impulse, with an increase in the
maximum angle of the knee and ankle and the hip extensor impulse, indicative of a distal-to-proximal redistribution of energy
absorption with fatigue [12]. However, the current study did not identify an effect of fatigue on the work performed by the hip,
although the work performed by the ankle joint increased significantly at the post-30% fatigue level. It is possible that the hip
plays an adaptive role in lower limb shock absorption only after a general fatigue protocol of the lower limb; the current study
used a fatigue protocol that was local to the knee joint. This local fatigue at the knee is relevant to jump landings, and it was demon-
strated that for this specific task; the ankle makes a substantial contribution to shock absorption for cutting movements performed
after the landing.
The rate of loading on the lower limb is defined as the value of the normalized peak VGRF divided by time to peak VGRF. The
increase in the loading rate when high stress is applied to the lower extremity joints over a short time duration decreases its
shock absorption capacity [23]. Therefore, an increase in the loading rate increases the risk of injury to the joints of the lower
extremity [29–31]. The current study did not identify a significant change in PVGRF with increasing levels of fatigue. However,
the loading rates at post-30% and post-50% fatigue levels were significantly lower than at baseline, a result which is in contrast
with previously reported studies. This is presumably due to the increase in ROM of the ankle joint, which increased the time
to PVGRF. This ankle-specific adaptation could compensate for the decrease in the shock absorbing capacity of the knee joint
with increasing fatigue.

4.2. Kinematics and kinetics of lower extremity on landing height

The increase in VGRF with an increase in landing height from 30 cm to 40 cm may increase the risk of lower extremity injury
[32]. Ali et al. similarly reported an increase in VGRF with increasing landing height, which was associated with an increase in the
flexion angle at the knee and trunk, and magnitude of eccentric power and work performed by the knee [19]. Additionally, PVGRF
was also significantly correlated to ankle plantarflexion and knee flexion angles. As these changes in lower limb kinematics and
kinetics, which decrease the overall shock absorbing capacity of the lower limb, increase the risk for non-contact injuries to the

Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007
 Y. Kim et al. / The Knee xxx (2017) xxx–xxx 7

ACL injury during single-leg landing, the shock absorption capacity of the knee may be critical for protecting and promoting
appropriate muscle firing patterns to preserve the ACL.
The current study reported a significant decrease in ankle stiffness after fatigue. This finding differs from the results previously
reported by Farley and Morgenroth of a 1.9-fold increase in ankle stiffness and 1.7-fold increase in knee stiffness for a self-selected
hopping height to a maximum hopping height [26]. In their study, Farley and Morgenroth proposed that ankle stiffness provided
the primary mechanism for adjusting leg stiffness. On the other hand, Hobara et al. reported that the regulation of knee stiffness
during a two-legged maximal hop was the major determinant of leg stiffness [33]. Therefore, mechanisms for the regulation of
lower extremity stiffness may be task-dependent [26,33]. As such, the current finding of a decrease in ankle stiffness after fatigue,
compared to the increase reported by Farley and Morgenroth, might largely be explained by behavioral differences between
hopping and cutting after jump landings.
The role of an increase in ankle ROM in reducing stiffness of the ankle joint has previously been described [24], with the
resulting decrease in stiffness increasing the risk of injury to the soft tissues around the ankle [24,34,35]. The current findings
of an increase in knee stiffness under both post-50% and post-30% fatigue levels for landings performed from the 40-cm height
aligns with previously reported data [24,27]. This combination of decreased stiffness at the ankle and increase at the knee to
control landings from a higher height after fatigue would increase the risk for musculoskeletal injury during landing, due to an
inappropriate scaling of lower stiffness to the demands of landing [23]. Henning and Lafortune suggested that increased leg stiff-
ness was typically associated with reduced lower extremity excursions and an increase in peak force and loading rate [36], which
increases the likelihood of bony injuries under conditions of increasing PVGRF [23,37].
Similar to previous studies [28], the current study identified the need for an increase in the work performed by the lower
extremities for energy absorption for landings performed from a higher height with fatigue. Although Zhang et al. identified
knee extensor torque as an important contributor to energy dissipation [28], the current study identified an increased contribu-
tion by the ankle joint with increasing height and fatigue, concomitant with a decrease in the contribution by the knee. Variation
in the mechanism of shock absorption for various landing heights has previously been reported [19,22,28,32]. The mechanism
of decreased work at the knee would increase the risk of injury at both joints during the performance of cutting movements
performed after landing from a jump.
The limitations of the current study need to be acknowledged in the application of the results. First, the controlled laboratory
environment limited the generalization of the findings to typical sporting contexts. Second, participants performed planned,
pre-defined cutting movements, which may have been different from those observed in real sporting contexts. Third, sex-specific dif-
ferences were not examined. Fourth, the landing protocol was performed in a barefoot condition, to standardize conditions; however,
fatigue characteristics of the foot and the type of foot (supinated or pronated) were not considered. Finally, the fatigue protocol that was
used targeted only the knee extensors and flexors, with fatigue induced at a low speed (60°/s), and may not have been representative of
whole lower extremity fatigue experienced in real situations.

5. Conclusions

By comparing the effects of the post-50% and post-30% levels of knee muscle fatigue on lower limb control of cutting movements
performed after landing from a height of 30 cm and 40 cm, an increasing role of the ankle was identified in adapting lower limb stiff-
ness with increasing fatigue and height. In contrast, the shock absorbing capacity of the knee decreased. This adaptive strategy would
increase the risk of injury to both the ankle and knee after fatigue exceeding the post-30% threshold.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.knee.2017.09.007.

Conflicts of interest

The authors declare that no personal relationship exists that could have influenced this manuscript.

Acknowledgements

This study was supported by the Dong-A University research fund.

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Please cite this article as: Kim Y, et al, The effect of knee flexor and extensor fatigue on shock absorption during cutting movements
after a jump landing, Knee (2017), https://doi.org/10.1016/j.knee.2017.09.007