[ research report ]

JORDAN CANNON, MSc1,2  •  EDWARD D.J. CAMBRIDGE, BKin, DC2  •  STUART M. MCGILL, PhD2

Anterior Cruciate Ligament Injury

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Mechanisms and the Kinetic Chain

Linkage: The Effect of Proximal Joint
Stiffness on Distal Knee Control
During Bilateral Landings

N
euromuscular deficits of the trunk and hip musculature may loads, though multiplanar kinematics at
contribute to noncontact anterior cruciate ligament (ACL) the lower extremity joints can also con-
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tribute to dynamic valgus.21,50,57 Recent

injury mechanisms such as dynamic knee valgus. However,
evidence implicating aberrant trunk and
comprehensive examination and characterization of such hip kinematics in dynamic valgus behav-
deficits are incomplete in the literature. Dynamic knee valgus is char- ior provides a rationale for the mechanism
acterized by hip adduction and knee abduction when the knee has being a proximal-to-distal process.5,20,23,51
collapsed medially and joint structures experience excessively high The likelihood of dynamic valgus in-
ducing harmful ACL forces and strains
UUBACKGROUND: Neuromuscular deficits at the 1.3) and gluteus maximus transverse JRS (P =
has been documented previously in the
literature.18,25,33,36,59 Thus, evaluation of dy-
Journal of Orthopaedic & Sports Physical Therapy®

trunk and hip may contribute to dynamic knee valgus
and anterior cruciate ligament injury mechanisms.
However, comprehensive examination of neuromuscu-
lar patterns and their mechanical influence is lacking.
UUOBJECTIVES: To investigate the influence of
lumbar spine joint rotational stiffness (JRS) and
the gluteal musculature contribution to hip JRS on
dynamic knee valgus.
UUMETHODS: In this cross-sectional study, 18
university-aged women completed a drop vertical
jump while we measured kinematics, kinetics, and
24 channels of electromyography (EMG) spanning
the trunk and hip musculature. We classified
each limb as high or low valgus, based on frontal
plane knee displacement magnitude. We used
anatomically detailed, EMG-driven biomechanical
models to quantify lumbar spine JRS and muscle
contributions to hip JRS.
UURESULTS: Low-valgus limbs generated greater
gluteus medius frontal JRS (P = .002; effect size,
.003; effect size, 1.2) compared to high-valgus
limbs. Participants with bilateral high-valgus
collapse had substantially reduced lumbar spine
sagittal JRS compared to the group with low valgus
on both limbs (P = .05; effect size, 5.1). Those with
low valgus on both limbs also had a peak lumbar
spine flexion angle of 24° ± 4°, compared to the
bilateral high-valgus group’s angle of 38° ± 10° (P
= .09; effect size, 1.8).
UUCONCLUSION: Participants who avoided
high medial knee displacement had greater
proximal JRS. Increased JRS at the lumbar spine
and greater JRS contributions from the gluteal
musculature are linked with preventing high
medial knee displacement. J Orthop Sports Phys
Ther 2019;49(8):601-610. Epub 26 May 2019.
doi:10.2519/jospt.2019.8248
UUKEY WORDS: biomechanics, dynamic valgus,
hip, lumbar spine, musculoskeletal modeling
namic valgus as a measure of ACL injury
risk is well established.17,20-22,31,42,43,47,56 Giv-
en its utility in screening for injury risk,
the drop vertical jump (DVJ) is a common
task employed in research and the clinic
to evaluate dynamic valgus.22,28,42,44,47,48
However, beyond kinematic and kinetic
characterization and limited electromy-
ography (EMG) analyses, the work con-
ducted to understand the mechanism of
dynamic valgus has been insufficient. This
deficit motivated the current investigation
of muscle activation patterns and proxi-
mal joint stiffness.
A growing body of literature suggests
that many traumatic knee injuries are
due to aberrant hip kinematics.50 In the
sagittal plane, a trade-off exists between

1
Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. 2Spine Biomechanics
Laboratory, Department of Kinesiology, University of Waterloo, Waterloo, Canada. This study was approved by the University of Waterloo Office of Research Ethics. Funding was provided
by the Natural Sciences and Engineering Research Council of Canada. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a
direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Mr Jordan Cannon, Musculoskeletal Biomechanics Research Laboratory,
Division of Biokinesiology and Physical Therapy, University of Southern California, 1540 Alcazar Street, G8, Los Angeles, CA 90089. E-mail: cannonjo@usc.edu t Copyright ©2019
Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 | 601

 [ research report
the hips and knees upon bilateral land-
ing. In general, landing with an anterior
lean of the trunk has been associated
with decreased knee extensor moments
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and increased hip extensor moments;
conversely, landing with an erect trunk
has been associated with the reverse.50,51
Additionally, anterior-to-posterior trunk
lean serves to modulate the strain and
forces experienced by the ACL.4,29,50 In
the frontal and transverse planes, of par-
ticular importance is the role of hip ad-
duction and internal rotation as primary
contributors to medial knee displacement
(MKD) and a valgus posture.47,53,58 During
hip adduction, the knee joint moves me-
dially, allowing dynamic valgus and large
knee abduction moments to occur.20,58
Powers50 noted that females who relied
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
predominantly on the hip musculature
to absorb impact forces during landing
had reduced knee valgus angles, abduc-
tion moments, and energy absorption
at the knee. Several studies have noted
weakness in hip extension, external rota-
tion, and abduction in those who display
valgus during dynamic tasks or go on to
suffer knee injuries.1,14,57 However, it has
Journal of Orthopaedic & Sports Physical Therapy®
been demonstrated that dynamic valgus
and the associated mechanics can be re-
duced immediately following feedback
and technique coaching, indicating that
landing biomechanics are independent of
muscle strength.19,31,41
Hip abduction and external rotation
are predominantly achieved by the glute-
us medius and gluteus maximus, respec-
tively.27,45,60 As such, these are muscles of
interest when considering the mecha-
nism of dynamic valgus. To date, muscles
of the gluteal complex have been evalu-
ated only for their activation amplitude,
onset/offset timing, duration of activity,
and their link to aberrant hip kinemat-
ics.1,57,63 While such analyses are insight-
ful, they cannot provide direct evidence
regarding the mechanical contribution
of the muscle’s ability to resist kinemat-
ics contributing to dynamic valgus.
Considering the importance of control-
ling trunk and hip kinematics, it has been
postulated that neuromuscular factors
602 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy
are the primary mechanism of dynamic
valgus. Prospective studies have success-
fully predicted knee injury (inclusive of
ligamentous and meniscus) and ACL in-
jury in female participants with high sen-
sitivity (ranging between 84% and 91%)
when considering neuromuscular factors
related to core stability in their predictive
models.61,62 Furthermore, purposeful core
(trunk) muscular engagement has been
shown to decrease frontal plane hip dis-
placement and increase knee flexion an-
gle.55 Core stability has been defined as the
ability to dynamically control the trunk
over the pelvis in order to allow optimal
production, transfer, and control of forces
and motion to distal segments of the ki-
netic chain.26,61 Thus, the dynamic control
of the knee is dependent on all contribut-
ing segments to the movement, starting
proximally with the trunk and radiating
distally through the hips.
The role of trunk musculature to pro-
vide stiffness and stability to the spine is
well documented.3,7-9,12,49,52 The mechani-
cal stability of a joint depends on the
ability of active, passive, and control sys-
tems to contribute stiffness to the joint.
The control system includes the central
nervous system, which modulates joint
stiffness via surrounding muscular contri-
butions (active system).46 Muscle stiffness
is the elastic energy stored upon defor-
mation and is dependent on activation,
force, and length.9,13,30 Joint rotational
stiffness (JRS) is the elastic resistance to
rotational joint motion and is dependent
on muscle stiffness and the geometric
orientation (muscle attachment coordi-
nates, length, moment arm) of muscula-
ture about the joint.10-12 Muscle stiffness
and its contribution to JRS are a function
of neural drive in response to proprio-
ceptive feedback and the instantaneous
task-demand constraints.9,10,12,30,37 In
the absence of sufficient stiffness, joint
integrity is compromised, whereby in-
stability and aberrant joint micromove-
ments can occur, and/or structures may
be unable to resist perturbations and
excessive motion.12,38 Analyses of JRS
provide a unique method to encapsulate
]
the effect of musculature around a joint
of interest, by incorporating the effect
of active muscle stiffness and geometric
orientation given segment kinematics.
Quantification of JRS facilitates analy-
sis beyond muscle activation in isolation
and provides insight into the mechanical
ability of musculature to resist rotational
perturbations.
The evidence linking kinematic and
neuromuscular involvement of the trunk
and hip in dynamic valgus suggests that
a biologically robust method of investi-
gating proximal JRS in its ability to pre-
vent dynamic valgus is justifiable. The
relationship of muscle activation pat-
terns with safe or aberrant kinematics
has not been documented in the muscu-
lature of the trunk during a DVJ. Such
an analysis would be critical to inform-
ing evidence-based prevention strate-
gies. Lumbar spine mechanics were of
particular interest, given the hypothesis
that the mechanism is a proximal-to-dis-
tal process and that lumbar spine motion
influences trunk position, pelvic orienta-
tion, hip kinematics, and knee control.
Given the frontal and transverse plane
hip kinematics that create dynamic val-
gus, of specific interest at the hip were
the contributions of the gluteus medius
and gluteus maximus to JRS in the fron-
tal and transverse planes, respectively.
The purpose of this work was to conduct
a mechanistic investigation aimed at elu-
cidating and characterizing the proximal
neuromuscular mechanisms that con-
tribute to dynamic valgus.
We hypothesized that greater lumbar
spine flexion angles and reduced sagit-
tal plane lumbar spine JRS would be
observed in participants who displayed
bilateral valgus compared to those who
displayed no valgus on either limb. Ad-
ditionally, we hypothesized that limbs
characterized as low valgus would display
greater gluteus medius JRS in the frontal
plane and greater gluteus maximus JRS in
the transverse plane than limbs character-
ized as high valgus. The aim of this study
was to provide insight into the motor
control component of avoiding dynamic
 valgus by linking proximal JRS to the fron-
tal plane control of the knee joint. Insight
from the results of this study may inform
evidence-based interventions aimed at re-
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ducing dynamic valgus and, ultimately, an
individual’s risk of noncontact ACL injury.
METHODS
E
ighteen female participants
(mean ± SD age, 20.7 ± 1.3 years;
height, 1.64 ± 0.05 m; mass, 65.2 ±
11.0 kg) from a university population vol-
unteered for this cross-sectional study. To
be included, participants had to report no
current or significant previous injury and
no chronic or recurrent pain in the low
back or lower extremities. Female partici-
pants who were varsity and recreational
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
athletes from a variety of sports (soccer,
basketball, volleyball, rugby, martial
arts) were selected because they are at
high risk for ACL injury. Before testing,
each participant read and signed written
informed-consent forms approved by the
University of Waterloo Office of Research
Ethics.
Journal of Orthopaedic & Sports Physical Therapy®
Data Collection
DVJ Task  The DVJ involves the partici-
pant dropping both feet off a box (31 cm
FIGURE 1. The stages of a standard drop vertical jump from a 31-cm box onto 2 adjacent force plates. The participant begins with feet shoulder-width apart and the toes at the
edge of the box (A). The participant initiates movement by dropping with both feet off the box (B), landing each foot on a separate force plate (C), before performing a maximal
vertical jump (D) and landing back on the force plates (E).
journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 | 603
in height, 10 cm from the force plates)
and landing with each foot on a force
plate before performing a maximal ver-
tical jump (FIGURE 1). The DVJ was de-
scribed and demonstrated by a research
assistant. Participants were asked to land
with each foot on a force plate simulta-
neously and jump as high as they could,
before landing back on the force plates. A
trial was considered successful when both
feet hit the force plates simultaneously
and the participant reported performing
a maximal vertical jump. Additionally,
raw EMG signals were checked in real
time for quality and veracity. Any trials
with obvious nonphysiological spikes
due to mechanical collision or motion of
hardware were not considered successful.
Three successful trials of every task were
performed.
Kinematics and Kinetics The Vicon
Nexus (Oxford Metrics, Yarnton, UK)
motion-capture system tracked the 3-D
coordinates of reflective markers, sam-
pled at a rate of 60 Hz. Reflective markers
adhered over the following landmarks bi-
laterally allowed for segment definition:
first and fifth metatarsal heads, posterior
and inferior bases of the calcaneus, medi-
al and lateral malleoli, medial and lateral
femoral condyles, greater trochanters,
iliac crests, acromia, the sternum, and C7.
Rigid-body plates containing a minimum
of 4 reflective markers to track segment
movement during tasks were attached at
the following segments: feet, legs, thighs,
the sacrum, and T12. Ground reaction
forces and moments were recorded with
2 in-ground force plates (Advanced Me-
chanical Technology, Inc, Watertown,
MA) oriented adjacent to one another
and sampled at a rate of 2160 Hz.
Electromyography  Twenty-four chan-
nels of EMG were collected bilaterally
over the following muscles: the rectus
abdominis, external oblique, internal
oblique, latissimus dorsi, upper (thorac-
ic) erector spinae, lower (lumbar) erec-
tor spinae, tensor fascia latae, gluteus
medius, gluteus maximus, rectus femo-
ris, biceps femoris, and adductor longus.
Silver/silver chloride surface electrode
pairs were positioned with an interelec-
trode distance of approximately 2.5 cm
and oriented in series, parallel to the di-
rection of the muscle fibers.
Each participant performed a maxi-
mal voluntary isometric contraction of
each muscle for normalization. The EMG
signals were amplified and analog-to-dig-
ital converted with a 16-bit converter at a
sample rate of 2160 Hz, using the Vicon
 [ research report ]
Nexus (Oxford Metrics) system software.
Reference Voluntary Contraction A
reference voluntary contraction was col-
lected as a calibration procedure to tune
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the EMG-driven musculoskeletal models

to each participant. The reference volun-
tary contraction for the lumbar spine in-
volved the participant standing upright
and holding a 9.07-kg plate directly in
Anthropometric Kinematic data External force EMG
front of the body in both hands, with full data (force-plate data)
elbow extension and shoulders flexed to
approximately 90°. For the hips, a similar
reference voluntary contraction was used Link segment model
while the participants were in a semi-
squat position.

Data Processing 3-D reaction force 3-D joint angles

Kinematics  Visual3D software (C-Mo- and moment
tion, Inc, Germantown, MD) was used to
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

calculate functional joint centers of the

hip and knee.2,54 Three-dimensional joint Joint model Individual muscle Muscle model
length, velocity, (lumbar: DM)
kinematics were calculated in Visual3D PCSA (hip: Hill type)
using rigid-body segment clusters for
the lumbar spine (sacrum and T12), hips
Individual muscle
(pelvis and femur), and knees (femur generalized Individual muscle
and shank) and known anatomical land- coordinates force and stiffness
Least-squares
marks to form orthopaedic angles from difference
Euler rotation sequences in the following
Journal of Orthopaedic & Sports Physical Therapy®

Joint forces and

order: (1) flexion/extension; (2) lateral
bend of the spine, abduction/adduction
of the hip and knee; and (3) axial rotation
of the spine, internal/external rotation of
the hip and knee. Kinematic data were
low-pass, second-order Butterworth fil-
tered (dual pass) to produce a final cutoff
frequency of 6 Hz (effectively creating a
fourth-order, zero-lag filter).
A body-fixed hip-ankle plane was
created using the hip joint center, ankle
joint center, and a virtual marker (an-
terior to the ankle joint center) in Visu-
al3D (C-Motion, Inc) to calculate frontal
plane knee displacement throughout
the duration of the task. Frontal plane
knee displacement was calculated as
the perpendicular distance between the
functional knee joint center and the hip-
ankle plane. Medial knee displacement
represents a valgus posture of the lower
extremity. The peak MKDs of all trials
of the DVJ task were recorded before
calculating the median value. An exclu-
moments
Common gain
Joint rotational
stiffness analysis
FIGURE 2. An overview of the EMG-driven modeling processes used for the lumbar spine and hip is presented to
demonstrate the inputs, processing, and outputs of each subcomponent. Abbreviations: DM, distribution-moment
model; EMG, electromyography; PCSA, physiological cross-sectional area.
sion range of ±20% around the median valgus; or “no valgus,” when both limbs
was defined and provided the thresholds were low valgus.
to determine high- or low-valgus status Electromyography  Electromyography
for the given limb, such that high valgus data were digitally band-pass filtered be-
values were those greater than the me- tween 30 and 500 Hz using second-order,
dian plus 20%. Each limb’s valgus status zero–phase-lag (dual-pass) Butterworth
was independently defined; this split the filters.15 Steps in digitally processing the
groups into “high valgus” and “low valgus” raw EMG data included removing the
for the analysis of gluteal contributions to direct-current bias, full-wave rectification,
hip JRS. For the analysis of lumbar spine and computing the linear envelope using
variables, the participants were split into a low-pass Butterworth filter with a cutoff
3 groups: “bilateral valgus,” in which both frequency of 2.5 Hz.6 The filtered linear
limbs were classified as high valgus; “uni- envelope signal was then normalized to
lateral valgus,” when either limb was high the maximum muscle activation elicited

604 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy


Comparison of Peak Lumbar Spine Flexion and
TABLE 1
Sagittal JRS Between Valgus Groups*
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Effect Size
BV (n = 4) UV (n = 10) NV (n = 4) BV – UV BV – NV UV – NV
Lumbar Spine Flexion Angle, deg† 38 ± 10 (29, 46) 26 ± 8 (9, 44) 24 ± 4 (5, 43) 1.4 1.8 0.3
Lumbar Spine Sagittal JRS, Nm/rad‡ 646 ± 52 (418, 873) 833 ± 278 (339, 1327) 1099 ± 114 (571, 1627) 0.8 5.1 1.1
Abbreviations: BV, bilateral valgus; JRS, joint rotational stiffness; NV, no valgus; UV, unilateral valgus.
*Values are mean ± SD (90% confidence interval) unless otherwise indicated.
†
P = .09.
‡
P = .05.

plane displacement of the knee, they are

Comparison of Peak Gluteus Medius not included in our statistical analyses
Frontal Plane JRS and Gluteus as separate variables. Each limb’s valgus
TABLE 2
Maximus Transverse Plane JRS Between status was independently defined; there-
High- and Low-Valgus Groups* fore, groups of high and low valgus were
composed of the limbs defined as such.
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

HV Versus LV Comparisons between high- and low-val-

HV (n = 11) LV (n = 13) P Value Effect Size gus groups for gluteal JRS variables were
Gluteus medius frontal plane 1076 ± 708 (550, 1603) 2708 ± 1505 (1450, 3965) .002† 1.3 done using t tests, correcting for mul-
JRS, Nm/rad tiple comparisons using the Bonferroni
Gluteus maximus transverse 290 ± 194 (145, 434) 698 ± 431 (353, 1043) .003† 1.2 method. To test the association between
plane JRS, Nm/rad gluteal JRS measures and MKD, multiple
Abbreviations: HV, high valgus; JRS, joint rotational stiffness; LV, low valgus. linear regression was performed. Statisti-
*Values are mean ± SD (90% confidence interval) unless otherwise indicated.
†
Statistically significant after correcting for multiple comparisons. cal significance was set at the P<.05 level
for all tests. All statistical analyses were
Journal of Orthopaedic & Sports Physical Therapy®

performed in R (R Foundation, https://

during the maximal voluntary isometric anatomical data from the Twente lower www.r-project.org).
contraction for the given muscle. Electro- extremity model.27
myography data were then down-sampled RESULTS
to be time synchronized with kinematic Statistical Analysis

data sampled at 60 Hz.
EMG-Driven Modeling to Estimate
JRS  Details of the EMG-driven model-
ing processes (FIGURE 2) and methods to
estimate JRS at the lumbar spine and
hips can be found in detail in the APPENDIX
(available at www.jospt.org). Anatomi-
cally detailed, EMG-driven biomechani-
cal models of the lumbar spine and hips
(comprising 228 muscle fascicles in total)
that were sensitive to individual move-
ment and motor control strategies were
used. Lumbar spine JRS was calculated
using a stability analysis that evaluates
the potential energy of the system.12,24,35,39
In order to calculate gluteus medius and
gluteus maximus contributions to hip
JRS, equations developed by Potvin and
Brown49 were used in conjunction with
For each participant, peak variables of
interest were calculated as the average of
3 successful trials. Lumbar spine flexion
and lumbar spine sagittal JRS were pri-
mary variables of interest for comparison
between the 3 groups defined by both
limbs’ valgus status (bilateral valgus, uni-
lateral valgus, no valgus). A 1-way analy-
sis of variance was conducted to compare
the groups. Additionally, the summation
of each limb’s peak MKD allowed for a
continuous variable to be used in simple
linear regression with each lumbar spine
measure. Hip variables of interest were
peak gluteus medius frontal plane hip
JRS and gluteus maximus transverse
plane hip JRS. As hip kinematics are in-
herently considered within the JRS anal-
ysis and directly contribute to the frontal
T
he mean peak MKD was 1.7 ± 0.8
cm, the median value was 1.8 cm,
and the thresholds for determin-
ing high and low valgus were 2.1 cm and
1.4 cm, respectively. The mean ± SD and
90% confidence intervals are presented
for lumbar variables (TABLE 1) and gluteal
JRS variables (TABLE 2). P values and ef-
fect size (Hedges’ g) are presented in the
tables for group comparisons.
The no-valgus group displayed a
peak lumbar spine flexion angle of 24°
± 4°, compared to the bilateral-valgus
group’s angle of 38° ± 10° (P = .09; ef-
fect size, 1.8) (TABLE 1). The peak lumbar
spine sagittal JRS between the no-val-
gus group (1099 ± 114 Nm/rad) and bi-
lateral-valgus group (646 ± 52 Nm/rad)
had a very large effect size (5.1, P = .05)

journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 | 605

 [ research report ]
(TABLE 1). Simple linear regressions for contact phase of the DVJ are displayed account for 39% of the variance in MKD,
lumbar spine flexion (FIGURE 3A) and sag- in FIGURE 4 for each group. indicating that a 1000-Nm/rad increase
ittal JRS (FIGURE 3B) show little variance Peak gluteus medius frontal plane JRS in either of the gluteal JRS measures
are accounted for when using data from (P = .002; effect size, 1.3) and gluteus would result in a 1-cm decrease in MKD
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all valgus groups (23% and 7%), but a maximus transverse plane JRS (P = .003; (TABLE 3). FIGURE 5 graphically displays the
moderate amount of the variance is ex- effect size, 1.2) were significantly greater summation of peak gluteus medius and
plained when considering the data of in the low-valgus compared to the high- gluteus maximus JRS in the frontal and
only the bilateral-valgus and no-valgus valgus group (TABLE 2). When entered transverse planes as a function of MKD.
groups (56% and 61%). Average time-se- into the multiple linear regression model
ries data of lumbar variables during the (P<.001), gluteal JRS contributions could DISCUSSION

T
A
he primary results of this study
indicate that those who avoided high
6.0 MKD utilized greater proximal JRS.
Specifically, low-valgus limbs generated
Summed Medial Knee Displacement, cm

5.0 greater gluteal JRS compared to high-

valgus limbs. Remarkably, even with only
4.0 4 participants in each group, large effect
sizes indicate that participants displaying
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

3.0 bilateral valgus also collapsed into lum-

bar spine flexion and displayed substan-
2.0 R2 = 0.23
tially reduced lumbar spine sagittal plane
R2 = 0.56 JRS compared to the no-valgus group.
1.0
The data collection and postprocessing
required to estimate JRS are extensive
0.0
and limit the number of cases that can be
15 20 25 30 35 40 45 50 reasonably examined. Looking at the ex-
Lumbar Spine Flexion Angle, deg tremes of behavior and response enhances
Journal of Orthopaedic & Sports Physical Therapy®

B
the biological significance, as the purpose
of this work was to explore why some peo-
6.0
ple display valgus while others do not. This
Summed Medial Knee Displacement, cm

study was not an investigation of the be-

5.0
havior of the group about a mean; rather,
4.0
it observed the features of those who are at
the extremes—that is where the signal of
3.0 interest is. Stiffness is the variable the mo-
R2 = 0.07 tor control system uses to control motion
2.0 throughout the linkage, and these results
suggest a key role for proximal stiffness in
1.0 preventing dynamic valgus.
R2 = 0.61
We hypothesized that greater lumbar
0.0 spine flexion angles and reduced sagit-
500 700 900 1100 1300
tal plane lumbar spine JRS would be
Lumbar Spine Sagittal JRS, Nm/rad
observed in participants who displayed
bilateral valgus compared to those who
No valgus Unilateral valgus Bilateral valgus displayed no valgus. Such small sample
All groups Bilateral- and no-valgus groups sizes do not allow for sufficient statisti-
FIGURE 3. Scatter plots of (A) lumbar spine flexion angle and (B) lumbar spine sagittal JRS versus summed medial
cal power, and, as such, conventional
knee displacement during the drop vertical jump task. Gray dashed lines are the regression fit considering all groups’ significance parameters were not likely
data, and black solid lines are the regression fit on only the bilateral-valgus and no-valgus data. Note the clustering of to be reached. Despite this limitation, the
no-valgus and bilateral-valgus groups at either end of the spectrum. High summed medial knee displacement values groups were remarkably different in their
in the unilateral-valgus group may be driven primarily from 1 limb. Abbreviation: JRS, joint rotational stiffness.
peak lumbar spine flexion and lumbar

606 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy

 spine sagittal plane JRS (TABLE 1, FIGURE
4), as indicated by very large effect sizes.
Therefore, we suggest that these results
hold biological significance of consider-
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medius’ frontal plane JRS contribution. ment and the results of this work (TABLE
The reported threshold values for MKD 3), a 1000-Nm/rad decrease in either of
used in this work correspond reasonably the gluteal JRS measures would increase
well with values by a prospective study one’s risk of ACL injury by 33%.

able weight, particularly because this is that reported that a 1.2-cm increase in Hip flexion magnitudes between the
the first study of its kind to comprehen- MKD increased one’s risk of ACL injury bilateral-valgus and no-valgus groups dif-
sively evaluate trunk musculature in re- by 40%.28 Considering their risk assess- fered by less than 5°. This suggests that
lation to dynamic valgus during a DVJ.
Regarding the hip, we hypothesized that A
Bilateral Valgus Unilateral Valgus No Valgus
limbs classified as low valgus would dis-
40
play greater gluteus medius JRS in the
frontal plane and greater gluteus maximus Angle, deg 30
JRS in the transverse plane compared to
20
high valgus. Large effect sizes between
groups were observed in addition to sta- 10
tistical significance, thus highlighting the 0
importance of gluteus medius and gluteus 0 25 50 75 100 0 25 50 75 100 0 25 50 75 100
maximus mechanical contributions to the B
prevention of dynamic valgus.
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Landing tasks are complex in that they

1000
involve multijoint control and segment
coordination, while necessarily meeting
JRS, Nm/rad

the mechanical demands imposed by im- 750

pact forces at both the individual joints
and the kinetic chain as a whole.40 As 500
such, a variety of muscle activation pat-
terns and coordination strategies may
250
be utilized to achieve the goals of the
Journal of Orthopaedic & Sports Physical Therapy®

0 25 50 75 100 0 25 50 75 100 0 25 50 75 100

task and support moment demands at
Time (normalized as % total movement)
various joints and in multiple planes of
motion. The finding that the gluteal JRS FIGURE 4. Average time-series data of (A) lumbar spine flexion angle and (B) sagittal plane lumbar spine JRS
contribution was significantly different during the stance phase of the drop vertical jump task for each group. Abbreviation: JRS, joint rotational stiffness.
between high- and low-valgus limbs,
while explaining a moderate amount
of variance (39%), indicates that it is a Results of the Multiple Linear
TABLE 3
factor contributing substantially to the Regression Model*
control of the lower extremity during
landing—but not the only factor. Impor- Medial Knee Displacement†
tantly, though, the statistical power of the Gluteus medius frontal plane JRS –0.001 (0.0004)‡
regression analysis suffers due to a small Gluteus maximus transverse plane JRS –0.001 (0.001)
number of data points in our sample. Constant 2.537 (0.257)§
The mechanical function of the glu- Observations, n 36
teus medius and gluteus maximus sub- R2 0.392
stantiates their role in JRS production Adjusted R2 0.355

in those who avoided dynamic valgus, as Residual standard error 0.863 (df = 33)

their frontal and transverse plane mo- F statistic 10.641 (df = 2, 33)§

ment arms make them ideal stiffeners in Abbreviation: JRS, joint rotational stiffness.
*Using the gluteal musculature JRS variables as predictors of medial knee displacement, the model
combination with muscle activation. Be- was significant (P<.01), as denoted by the F statistic. The coefficients indicate that a 1000-Nm/rad
cause MKD is primarily a frontal plane increase in either gluteal JRS measure would result in a 1-cm decrease in medial knee displacement.
motion, it is unsurprising that the larg-
†
Medial knee displacement.
‡
P<.1.
est magnitude of difference between high §
P<.01.
and low valgus was found in the gluteus

journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 | 607

 [ research report
the no-valgus group avoided landing
erect but did not collapse at the lumbar
spine, thus achieving an anterior trunk
lean using a hip strategy to appropri-
Downloaded from www.jospt.org at Lithuanian Universit y of Health Sciences on March 26, 2020. For personal use only. No other uses without permission.
ately control the center of mass. This
highlights the need to quantify and un-
derstand how the anterior trunk lean is
achieved (via contributions from lumbar
spine and/or hip flexion) and the differ-
ences in mechanics that accompany such
strategies during dynamic tasks.
Several works have linked a “stiffen-
ing strategy” (less trunk, hip, and knee
flexion upon landing) to increased ACL
injury risk, given the increased load-
ing at the knee joint.4,31,32,50 A few stud-
ies have evaluated “stiffness” in varying
forms, including an average leg stiffness
(peak vertical ground reaction force/
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
body center-of-mass displacement)34 and
hip joint stiffness (moment/angle),16 but
have conflicting conclusions regarding
the difference in stiffness between male
and female participants and its relation
to ACL injury risk. However, such meth-
ods of calculating stiffness did not utilize
measures of the direct contribution of ac-
tive musculature, and this is the strength
Journal of Orthopaedic & Sports Physical Therapy®
of our investigation. We are not aware of
any previous works that have investigated
JRS at the lumbar spine or hip muscu-
3.0
Medial Knee Displacement, cm
2.0
1.0
0.0
0 2000
Gluteal Musculature JRS, Nm/rad
High valgus
FIGURE 5. The scatter plot displays the gluteal musculature’s combined contribution to hip JRS in the frontal and
transverse planes versus peak medial knee displacement during the drop vertical jump task. Abbreviations: JRS,
joint rotational stiffness; NA, not applicable.
608 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy
lature as it relates to the mechanism of
dynamic valgus or ACL injury, nor have
any works investigated the role of the
trunk and hip musculature to the extent
of this work.
The major limitation of this work is
the small sample size, rendering statis-
tical models lacking in sufficient power
for some variables. Eighteen university-
aged female recreational- or university-
level athletes comprised the sample. The
use of thresholds to define valgus groups
further reduced the sample size for group
comparisons and only provided relatively
high or low valgus based on the sample
population, while it also included both
limbs from some participants and only
single limbs from others. Given the cross-
sectional study design, small sample size,
and large variability in variables of inter-
est, inferences for the risk of injury as it
relates to reduced proximal JRS, while
promising, require further investigation.
Inherent assumptions and limitations
exist in the use of generic EMG-driven
biomechanical models. However, we at-
tempted to address these limitations by
tuning the model with a participant-
specific gain factor and using the be-
tween-group comparison to render any
error systematic in nature. This mecha-
4000 6000 8000
Low valgus NA
]
nistic study was designed to understand
potential contributing factors to, and
mechanisms of, dynamic valgus. For par-
ticipants in whom a limb had conflicting
valgus classification across trials, the ki-
nematic and JRS variables of each trial
often varied in magnitude. Averaging
these trials occasionally resulted in wash-
ing out differences between trials. Impor-
tant mechanistic information might exist
in this variability that may be insightful
for inferring injury risk.
CONCLUSION
T
his is the first work of its kind
to specifically characterize lum-
bar spine and hip neuromuscular
mechanisms that may be responsible
for dynamic valgus in the DVJ task, be-
yond EMG analysis of limited muscles.
Increased JRS at the lumbar spine and
greater JRS contributions from the glu-
teal musculature are linked with pre-
venting high MKD. Increased stiffness
is not always prophylactic, as extremely
high magnitudes may act to impose rigid-
ity within a system and prevent motion
that may be necessary to dissipate forces
and transfer energy in a manner that re-
duces injury risk. However, in this work,
increased stiffness was deemed to be ap-
propriate and sufficient, as it was regular-
ly a precondition to prevent high MKD.
Stiffness is a variable that is tuned by the
motor control system, with trade-offs
between motion, stress distribution and
migration, injury resilience, and perfor-
mance. This advance provides a spring-
board for future work to develop training
interventions for increasing proximal
JRS to avoid dynamic valgus during con-
trolled and uncontrolled tasks. t
KEY POINTS
FINDINGS: Neuromuscular factors at the
trunk and hip may be responsible for
dynamic valgus occurrence during a
landing task. Specifically, an inability to
generate sufficient proximal joint rota-
tional stiffness allows for high medial
knee displacement.
 IMPLICATIONS: Prevention programs
aimed at addressing neuromuscular
mechanisms related to noncontact
anterior cruciate ligament injury must
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consider both the trunk and gluteal
musculature, and their coordinated
activity to appropriately control the
linkage. Assessing joint rotational stiff-
ness facilitates analysis beyond muscle
activation in isolation and advances
understanding of the links inherent to
cause and effect.
CAUTION: The joint rotational stiffness
described in this work is not equivalent
to “clinical stiffness.” When muscles con-
tract, they create both force and stiffness
that work together to control posture and
dynamic movement. Additionally, one
must train sufficient stiffness in individu-
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
als with appropriate and coordinated
muscle activation patterns in combina-
tion with suitable movement patterns.
The optimal value of stiffness that is both
appropriate and sufficient is unknown.
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 [ research report ]
APPENDIX
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ANTERIOR CRUCIATE LIGAMENT INJURY MECHANISMS AND THE KINETIC CHAIN LINKAGE
Methods
Lumbar Spine Model
Lumbar spine JRS was quantified using a 3-D, anatomically detailed lumbar spine model (FIGURE 2) (including 98 laminae of muscle and a passive
lumped parameter stiffness element) that is sensitive to individual movement and motor control strategies.4 Briefly, normalized EMG data and lumbar
spine generalized coordinates are input into the model. A DM model is utilized to process the EMG and output muscle force and stiffness profiles, with
consideration of length and velocity.4,9 The stability analysis calculates the potential energy of the system, utilizing the elastic energy of linear and tor-
sional springs (APPENDIX FIGURE). The resulting 18-DoF lumbar spine model produces an 18 × 18 symmetric square Hessian matrix of the second-order
partial derivatives of the potential energy function with respect to general displacements along each DoF.3,4,7 The potential energy function is a summa-
tion of the contributions from the muscle fascicles (linear springs), passive tissues (torsional springs), and any externally applied loads. Each diagonal
element of the Hessian matrix represents the JRS about a particular axis of a joint in the lumbar spine; of interest in this work were the 3 axes about
L4-L5, because this is where the most anatomical detail is contained in the model. For the purposes of this work, the analysis stops here so that the
continuous measure of JRS can be examined with respect to medial knee displacement.

Lumbar spine
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

UL = ∑ Fm(lpm – lam) + ½ Km(lpm – lam)2 stability analysis

Individual muscle force Potential energy of spine system

V = UL + UT – W
Potential energy stored in linear
Individual muscle stiffness
springs (muscles): UL
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Individual muscle length Second derivative of V

Potential energy stored in torsional
Lumbar spine geometry
springs (passive tissues): UT
18 × 18 Hessian matrix (H)

Work performed on external

External load
load: W
Diagonalization of H

18 eigenvalues

FIGURE. An overview of the stability analysis run following the lumbar spine model. For this work, the values of interest were the joint rotational stiffness values of L4-L5
contained in the Hessian matrix (H). Thus, the diagonalization of H to obtain stability was not necessary.

Hip Model
In order to calculate hip JRS, equations developed by Potvin and Brown12 were used in conjunction with anatomical data reported by Klein Horsman
et al.8 An overview of the modeling processes that provide the variables necessary for the hip JRS analysis can be seen in FIGURE 2. Use of the JRS
equation (equation 1) requires input of (1) origin and insertion coordinates of muscles relative to the hip joint center, (2) muscle force, and (3) muscle
stiffness.

(1)

where JRSx is the rotational stiffness contribution of a muscle about the x-axis of the hip joint, F is the force of a particular muscle “m,” l is the 3-D
length of the muscle vector that crosses the hip joint, L is the full 3-D length of the muscle, r is the 3-D muscle moment arm, Ax,Ay,Az are origin coordi-
nates with respect to the hip joint center at (0, 0, 0), Bx,By,Bz are insertion (or initial-node) coordinates with respect to the hip joint center at (0, 0, 0),
and q is the muscle stiffness coefficient relating muscle force and length.

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APPENDIX
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(1) Origin and Insertion Coordinates

Origin and insertion coordinates of all relevant hip musculature (65 muscle fascicles per hip) were taken from the Twente lower extremity model.8
Muscles were split into anatomically and functionally relevant muscle parts, where several elements are used to model the muscle geometry most
accurately.

(2) Muscle Force

Instantaneous muscle forces were calculated using a Hill-type muscle model considering normalized EMG, corrections for length and velocity, and pas-
sive contributions (equation 2).11 Muscle characteristics (PCSA, Lo, pennation angle) required in the hip muscle force calculations were taken from the
Twente lower extremity model.8

(2)

where Fm is muscle force (Newtons), G is participant-specific gain, is normalized EMG amplitude, PCSA is physiological cross-sectional area,

Lo is optimal muscle length, σmax is maximum muscle stress, Ω is the coefficient for force-velocity correction, δ is the coefficient for force-length correc-

tion, and FPEC is the force due to the passive elastic component.
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Differences in the hip musculature’s mechanistic capability were preserved; however, some deep muscle activation was implied from surface EMG
sites.6 This method is sufficiently valid in providing insight for biomechanical analyses.2,6,10 Since muscles were evaluated for their contribution to JRS
and compared between groups, any error is systematic in nature.

(3) Muscle Stiffness

Muscle stiffness estimates were calculated via the method introduced by Bergmark.1

(3)
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where k is muscle stiffness, F is muscle force, L is total muscle length from origin to insertion, and q is the muscle stiffness coefficient relating muscle
force and length.
Reference Voluntary Contraction
A reference voluntary contraction was collected for the lumbar spine and each hip in order to account for discrepancies in model prediction of the
joint moment. The procedure used in this work minimizes the total sum of squared differences between the joint moment calculated using the linked-
segment model (MLSM) and that of the anatomically detailed EMG-driven model (MEMG) (FIGURE 2) using a least-squares-difference approach (equation
4). Specifically, a common gain factor (G) was calculated for each joint of interest of a given participant, to be applied to estimates of muscle force and
stiffness. In this way, the model was adjusted to fit each participant in order to account for between-participant differences in factors that influence the
EMG-to-force transformations, such as muscle morphology.5

(4)

Abbreviations: DM, distribution moment; DoF, degree of freedom; EMG, electromyography; JRS, joint rotational stiffness; PCSA, physiological cross-sectional area.

References
1. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230:1-54. https://doi.org/10.3109/17453678909154177
2. Brown SH, Potvin JR. The effect of reducing the number of EMG channel inputs on loading and stiffness estimates from an EMG-driven model of the spine. Ergonomics.
2007;50:743-751. https://doi.org/10.1080/00140130701194926
3. Cashaback JG, Potvin JR. Knee muscle contributions to joint rotational stiffness. Hum Mov Sci. 2012;31:118-128. https://doi.org/10.1016/j.humov.2010.12.005
4. Cholewicki J, McGill SM. Mechanical stability of the in vivo lumbar spine: implications for injury and chronic low back pain. Clin Biomech (Bristol, Avon). 1996;11:1-15.
https://doi.org/10.1016/0268-0033(95)00035-6
5. 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;28:321-325, 327-331. https://doi.org/10.1016/0021-9290(94)00065-C
6. Heller MO, Bergmann G, Kassi JP, Claes L, Haas NP, Duda GN. Determination of muscle loading at the hip joint for use in pre-clinical testing. J Biomech. 2005;38:1155-
1163. https://doi.org/10.1016/j.jbiomech.2004.05.022
7. Howarth SJ. Locating instability in the lumbar spine: characterizing the eigenvector [thesis]. Waterloo, Canada: University of Waterloo; 2006.
8. Klein Horsman MD, Koopman HF, van der Helm FC, Prosé LP, Veeger HE. Morphological muscle and joint parameters for musculoskeletal modelling of the lower extremity.

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 APPENDIX
Downloaded from www.jospt.org at Lithuanian Universit y of Health Sciences on March 26, 2020. For personal use only. No other uses without permission.

Clin Biomech (Bristol, Avon). 2007;22:239-247. https://doi.org/10.1016/j.clinbiomech.2006.10.003

9. Ma SP, Zahalak GI. A distribution-moment model of energetics in skeletal muscle. J Biomech. 1991;24:21-35. https://doi.org/10.1016/0021-9290(91)90323-F
10. McGill S, Juker D, Kropf P. Appropriately placed surface EMG electrodes reflect deep muscle activity (psoas, quadratus lumborum, abdominal wall) in the lumbar spine. J
Biomech. 1996;29:1503-1507. https://doi.org/10.1016/0021-9290(96)84547-7
11. McGill SM, Norman RW. 1986 Volvo Award in Biomechanics: partitioning of the L4-L5 dynamic moment into disc, ligamentous, and muscular components during lifting.
Spine (Phila Pa 1976). 1986;11:666-678.
12. Potvin JR, Brown SH. An equation to calculate individual muscle contributions to joint stability. J Biomech. 2005;38:973-980. https://doi.org/10.1016/j.
jbiomech.2004.06.004
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