Physiotherapy Theory and Practice, 25(2):69–98, 2009

Copyright r Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.1080/09593980802686953

Can vastus medialis oblique be preferentially activated?

A systematic review of electromyographic studies
Toby O Smith, BSc (Hons), MCSP,1 Damien Bowyer, MSc, BSc
(Hons), MCSP,2 John Dixon, PhD, BSc (Hons),3 Richard
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Stephenson, PhD, MSc, BA, MCSP,4 Rachel Chester, MSc,

1
MMACP, MCSP,5 and Simon T Donell, FRCS(Orth), MD6
Senior Orthopaedic Physiotherapist, Physiotherapy Department, Norfolk and Norwich University Hospital,
Norwich, UK
2
Senior Musculoskeletal Physiotherapist, Norfolk Community Health Care, Physiotherapy Outpatient
Department, Wymondham Health Centre, Wymondham, UK
3
Senior Lecturer in Research, Centre for Rehabilitation Sciences, School of Health and Social Care, University
of Teesside, Middlesbrough, UK
4
Reader in Physiotherapy, Faculty of Health, University of East Anglia, Norwich, UK
5
Lecturer in Physiotherapy, Clinical Physiotherapy Specialist, Physiotherapy Department, Norfolk and
For personal use only.

Norwich University Hospital, Norwich, UK and Faculty of Health, University of East Anglia, Norwich, UK
6
Honorary Reader in Musculoskeletal Disorders, Faculty of Health, University of East Anglia, Norwich, UK

Debate exists as to whether the vastus medialis oblique (VMO) can be activated to a greater degree
than the vastus lateralis to produce preferential strengthening. This systematic review aims to determine
whether preferential activation of VMO can be achieved by altering lower limb joint orientation or
muscular co-contraction. A search of pertinent specialist journals and of the electronic databases AMED,
CINAHL, the Cochrane database, EMBASE, ovid Medline, Physiotherapy Evidence Database
(PEDro), Pubmed, and Zetoc from their inception to February 2008 was undertaken. All English-
language clinical papers assessing the electromyographic activity of the human VM against the vastus
lateralis (VL) muscles, in a neutral lower limb joint orientation, compared to a different hip, knee, ankle,
and foot position; or with the addition of a co-contraction were included. Twenty papers reviewing 387
participants were reviewed. These reported principally that altering lower limb joint orientation or the
addition of a co-contraction does not preferentially enhance VMO activity over VL. Nonetheless, the
evidence-base presented with a number of significant methodological limitations. Accordingly, well-
designed studies evaluating large samples of patients with patellofemoral joint disorders are required, to
rectify the present limitations in the evidence-base, and to thoroughly investigate this topic.

Introduction oblique (VMO), and the vastus lateralis (VL)

muscles, may be an aetiological factor in the
It has been hypothesised that an imbalance development of patellofemoral pain syndrome
between the distal portion of the vastus medialis (Cowan et al, 2002; McClinton, Donatell, Weir,
(VM), commonly referred to as the vastus medialis and Heiderscheit, 2007; Souza and Gross, 1991).

Accepted for publication 31 May 2008.

Address correspondence to Toby O Smith, Physiotherapy Department-Out-Patients East Norfolk and Norwich University
Hospital, Colney Lane, Norwich NR4 7UY, UK. E-mail: toby.smith@nnuh.nhs.uk

69
 70 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
Furthermore, preferential atrophy or inhibition of
the VMO may contribute to patellar instability,
by permitting VL to exert a relatively greater late-
ral force, displacing the patella from its normal
position within the femoral trochlea (Grabiner,
Koh, and Draganich, 1994; Møller et al, 1987;
Panagiotopoulos, Strzelczyk, Herrmann, and
Scuderi, 2006; Taskiran et al, 1998). In this
regard, it has been proposed that the VMO should
be specifically strengthened to increase medial
dynamic stabilisation of the patella in these
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patient groups (Bicos, Fulkerson, and Amis, 2007;
Boling et al, 2006; Burks, 1992; Cowan et al,
2002; Crossley, Cowan, McConnell, and Bennell,
2005; Panagiotopoulos, Strzelczyk, Herrmann,
and Scuderi, 2006; Scudero and McCann, 2005;
Solomon, Warwick, and Nayagam, 2001). To
address this muscle imbalance as a treatment, the
VMO must be preferentially strengthened through
exercises that induce a selective training effect
over other quadriceps muscles (Grabiner, Koh,
and Draganich, 1994).
Electromyography (EMG) has been used to
For personal use only.
measure the relative activation levels of VMO
and VL during exercises (Cerny, 1995; Zakaria,
Harburn, and Kramer, 1997). This is represented
as absolute individual VMO vs. VL activity or
as a ratio value for VMO/VL, where greater ratios
indicate relatively greater levels of VMO activity.
To inform on potential training effects, EMG data
are usually normalised (expressed as a percentage
of the maximum possible voluntary activation
level), where preferential VMO activation is a
VMO/VL ratio greater than 1. Previous literature
has suggested that altering hip, knee, ankle or
forefoot position, or co-contractions of lower
extremity muscle groups whilst exercising the
quadriceps, may preferentially recruit and enhance
VMO activity (Eburne and Bannister, 1996;
Hodges and Richardson, 1993; Lam and Ng,
2001; McConnell, 1996; McConnell, 2002; Willis
et al, 2005). However, there is a conflicting body of
evidence to suggest that the VMO cannot be pre-
ferentially strengthened (Cerny, 1995; Herrington
et al, 2006; Livecchi et al, 2002). This is clinically
important because exercises that simply produce
overall strengthening of the entire quadriceps
complex may not improve any putative medial-
lateral muscle imbalance.
Acknowledging the uncertainty surrounding
whether the VMO can be selectively activated and
whether limb position or co-contraction can pre-
ferentially enhance VMO activity, an initial lit-
erature review was performed. This suggested that
no formal systematic review has been undertaken
to answer this research question. The aim of this
study was to systematically review the evidence
assessing whether performing quadriceps exercises
with co-contraction of other lower extremity
muscle groups, or by altering lower limb position
can preferentially activate the VMO.
Methodology
Study selection
Papers were included if they were primary
research directly comparing the EMG activity of
the VMO, or VM, to the VL, in a neutral lower
limb joint orientation, compared to a different
hip, knee, ankle, or foot position, or assessing
quadriceps contractions with or without addi-
tional lower extremity muscle co-contractions;
human studies recruiting either healthy asympto-
matic subjects or symptomatic subjects presenting
with patellofemoral musculoskeletal disorders; full
text, English language publications; nonspecific
with respect to subject gender or age. Papers
assessing the EMG activity of VM were included
in this review to ensure that we did not omit any
publications assessing the distal portion of VM
(i.e., VMO), which may have been termed VM.
The following papers were excluded: papers
that only assessed altered knee flexion-extension
angulations; non-English language papers; animal
studies; unpublished material such as university
theses and dissertations; comments, letters, edito-
rials, protocols, guidelines, abstracts, conference
proceedings, or review papers. Review papers
were excluded to permit a critical appraisal of
each original publication. Reference lists identi-
fied from such review articles were examined for
papers that were not identified by the search
strategy. Studies that assessed the proximal VM
or VML, or studies that did not specifically
compare EMG activity of the VMO or VM to the
VL muscle were excluded.
Search strategy
An electronic search was conducted by using
eight medical databases (AMED, CINAHL, the
 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
Cochrane database, EMBASE, ovid Medline,
Physiotherapy Evidence Database (PEDro),
Pubmed, and Zetoc) from their inception to
February 2008. The following key terms and
Boolean operators were utilised for each search:
knee AND electromyography AND patella. The
search terms applied were deliberately general to
attempt to obtain all the possible citations per-
taining to this research question. A hand-search
was undertaken of specialist journals related to
this research question: The Knee (1994–February
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2008), American Journal of Sport Medicine
(1987–February 2008), the British Journal of
Sports Medicine (1987–February 2008), and the
Journal of Electromyography and Kinesiology
(1991–February 2008).
Two reviewers (TS, DB) independently assessed
the titles and abstracts of all identified citations
against the selection criteria. The full manuscripts
were obtained for those papers deemed appro-
priate, or when the abstract did not clearly
demonstrate whether the study satisfied the cri-
teria. The reference lists of the full manuscripts
For personal use only.
were screened for any publications not identified
through the previous searches. The full texts were
again evaluated against the selection criteria by the
same two independent reviewers. Each paper
needed to fully satisfy the selection criteria to be
included. Papers were not excluded on poor
methodological quality.
Data extraction
Data extraction was performed by two
reviewers (TS, DB) independently. An extrac-
tion form, based on that utilised by Chester et al
(2008), was used to extract the following data
from each paper:
K Study design
K Sample size at the beginning and end of the
trial
K Important population characteristics and
potential confounding variable to study
results, these included pathology, age, gender,
height, and level of sporting activity
K Source and method of recruitment
K Method of EMG testing including testing posi-
tion, exercises performed and position of knee
and other lower limb joint or co-contractions
described
71
K EMG equipment and electrode placement
K Results of EMG data of VM and VL for
testing procedures
K Clinical implications described within the test
K Any relevant methodological limitations
noted during critical appraisal.
Methodological quality assessment
The methodological quality for each paper
included in the review was examined by using
the Critical Appraisal Skills Programme tool for
observational study designs (CASP, 2007). This
12-item checklist assesses study validity, metho-
dological quality, and generalisability. This
appraisal tool was applied for this review as all
the papers included adopted an observational
study design. The included papers were assessed
by using this tool by the same two independent
reviewers. Any disagreement regarding paper
selection, data extraction, or CASP score was
resolved by discussion until consensus was met.
No arbitrator was recruited, because following
discussion, the two reviewers were consistently
in agreement.
Results
The search strategy is illustrated in Figure 1.
From an initial 2,593 citations, a total of 66
papers were retrieved as full text for scrutiny. Of
these, 46 were excluded from further analysis
by not adhering to the eligibility criteria. The
remaining 20 papers adhered to the selection
criteria and were included in this review. Five
studies assessed the influence of lower limb
co-contraction (Coqueiro et al, 2005; Earl,
Schmitz, and Arnold, 2001; Hertel, Earl, Tsang,
and Miller, 2004; Hodges and Richardson, 1993;
Tepperman, Mazliah, Naumann, and Delmore,
1986), 11 evaluated the effects of altering lower
limb joint orientation (Bos and Blosser, 1970;
Gregersen, Hull, and Hakansson, 2006; Herrington
et al, 2006; Hung and Gross, 1999; Lam and Ng,
2001; Livecchi et al, 2002; Miller, Sedory, and
Croce, 1997a; Serrrão et al., 2005; Wild, Franklin,
and Woods, 1982; Willis et al, 2005; Zakaria,
Harburn, and Kramer, 1997), whilst four investi-
gated both (Cerny, 1995; Karst and Jewett, 1993;
Laprade, Culham, and Brouwer, 1998; Mirzabeigi
 72 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

Articles identified by the electronic

search, hand-search and review of
reference lists. (n = 2593)

Foreign language papers (n =167)

English language studies identified by

the search strategy (n=2426)
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English language title or abstract not related

to the research question. (n =2360)

Full manuscripts retrieved for further

scrutiny (n = 66)

Articles not related to the research question

after evaluating the full manuscript. (n = 26)

Appropriate studies related to the

research question. (n = 40)
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Articles excluded as not adhering to the

eligibility criteria. (n = 20)

Appropriate studies related to the

research question, adhering to
eligibility criteria. (n = 20)

Articles excluded due to replication of data

presented. (n = 0)

Finally included and analysed articles

(n = 20)

Figure 1. QUORUM chart.

et al, 1999). Eighteen papers assessed the
EMG activity of VMO, two papers assessed
EMG activity of VM (Bos and Blosser, 1970;
Tepperman, Mazliah, Naumann, and Delmore,
1986). All papers evaluated the preferential activity
of the distal portion of VM compared to VL.
Accordingly, the term VMO is used to discuss both
the distal VM and VMO results analysed in this
systematic review.
The 20 included studies are summarised in
Table 1.
The 20 papers included a total of 387 subjects,
of which 300 were healthy asymptomatic parti-
cipants and 87 were patellofemoral pain syn-
drome patients. In the studies recruiting healthy
participants, sample size ranged from eight
(Hertel, Earl, Tsang, and Miller, 2004; Mirzabeigi
et al, 1999) to 43 (Herrington et al, 2006),
whereas in the studies of patellofemoral pain
syndrome subjects, samples ranged from six
(Miller, Sedory, and Croce, 1997a) to 18 (Wild,
Franklin and Woods, 1982; Willis et al, 2005).
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Table 1. A summary of the studies included in this systematic review, investigating whether altering lower limb joint positioning can preferentially affect VMO elec-
tromyographic activity.

Population
characteristics Contraction
Sample size gender; mean and Electrode type; Period of type for
and SD age (years) and sampling rate; signal EMG EMG
Study diagnosis height (cm) Test procedures processing Analysis Analysis

Bos and 16 asymp- M/F: 16/0 Isometric knee extension in 01 hip Surface electrode, Not stated Isometric
Blosser tomatic Age: 19–38 and knee flexion in standing; indwelling
(1970) (range) with ankle dorsiflexion and electrodes also used
Height: N/D femoral and tibial 601 external on 5 participants;
rotation; or in ankle neutral SR not stated; no
and hip abduction signal processing
Cerny 10 PFPS PFPS Isometric knee extension in 01 knee Indwelling electrode; Data Isometric and
(1995) 10 asymp- M/F: 1/9 flexion and isokinetic knee SR 2000 Hz; FWR integrated Isokinetic
tomatic Age: 26.9
80 extension from 301 to 01 knee and integrated over if exceeded
Height: N/D flexion with hip in neutral, 0.02 sec intervals; noise
Asymptomatic maximal internal rotation, normalised to threshold
M/F: 0/10 maximal external rotation; or in MVIC (95%
Age: 26.5
4.5 hip neutral with maximal resting
Height: N/D isometric hip adduction, EMG
maximum ankle dorsiflexion, during 2
maximal plantarflexion, or ankle sec baseline
neutral. Isometric knee extension period)
holds at 451 flexion with tibial
neutral, maximum internal,
maximum external rotation. WS-
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

SD exercises to 451 knee flexion

with subtalar unconstraint, in
maximum supination, maximum
pronation; SS to 451 knee flexion
with and without maximal
isometric hip adduction
(Continued)
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74
Table 1. A summary of the studies included in this systematic review, investigating whether altering lower limb joint positioning can preferentially affect VMO elec-
tromyographic activity (Continued).

Population
characteristics Contraction
Sample size gender; mean and Electrode type; Period of type for
and SD age (years) and sampling rate; signal EMG EMG
Study diagnosis height (cm) Test procedures processing Analysis Analysis

Coqueiro 10 PFPS PFPS SS at 451 knee flexion, 301 hip Surface electrode; SR 2nd–6th sec Isometric
et al 10 asymp- M/F: 0/10 abduction, with or without 2000 Hz; processed into the SS
(2005) tomatic Age: 23.2
2.7 maximal isometric hip by RMS, window position,
Height: adduction size not stated; average
158.0
0.1 normalised to EMG
Asymptomatic MVIC calculated
M/F: 0/10
Age: 21.8
2.5
Height:
165.0
0.04
Earl et al 20 asymp- M/F: 10/10 SS to 301 knee flexion with and Surface electrode; SR Average Isokinetic
(2001) tomatic Age: 28.1
5.9 without maximal isometric hip 1000 Hz; processed EMG
Height: 170.9 adduction by RMS, window calculated

11.0 size not stated; for entire
normalised to 4 sec
MVIC contraction
Gregersen 14 asymp- M/F: N/D Cycling with foot attached to Surface electrode; SR 4, 5 sec trials Isokinetic
et al tomatic Age: 28.0 (range pedal at 101, 51, 01 of ankle 1200 Hz; FWR & recorded
(2006) 18–30) supination or pronation LPF 10 Hz; over 5 min
Height: 182.0 normalised to period for
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

(range 173–191) maximum value each foot

during pedalling position.
Unclear
when 5 sec
trials taken.
Peak and
average
EMG used
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Herrington 43 asymp- M/F: 20/23 Isokinetic knee extension and SS Surface electrode; SR ‘‘a standar- Isokinetic
et al tomatic Age: 22.8
2.3 to 901 knee flexion, with hip in 2000 Hz; processed dised period
(2006) Height: N/D either neutral; 301 internal; or by RMS window (4 sec from
301 external rotation. All 20ms intervals; onset)’’
exercises performed against a normalised to
load equivalent to 10% MVIC
subject’s body weight
Hertel 8 asymp- M/F: 5/3 SS on 301 slope at 601 knee Surface electrode; SR Maximum Isometric
et al tomatic Age: 24.0
2.5 flexion with and without 1000 Hz; HPF RMS value
(2004) Height: maximal isometric hip 75 Hz; processed by over a 0.5
169.5
4.7 abduction and adduction RMS; sec window
normalisation not calculated,
used from 5 sec
contraction
Hodges 20 asymp- M/F: 0/20 OKC knee extension from 601 to Surface electrode; SR, Not stated Isometric
and tomatic Age: 19.5
0.8 01 knee flexion; and SS from not stated;
Richar- Height: 601 to 01 knee flexion, both processed by RMS,
dson 166.7
5.2 with and without isometric hip window not stated;
(1993) adduction at 15%, 50% and normalisation not
100% MVIC used
Hung and 20 asymp- M/F: 10/10 Isometric knee extension in 01 Surface electrode; SR The maxi- Isometric and
Gross tomatic Age: 29.4
5.7 knee flexion or a SS at 501 knee 500 Hz; processed mum mean Isotonic
(1999) Height: flexion with: forefoot neutral; by RMS 20 ms amplitude
168.9
8.0 101 supination; or 101 window; for the
pronation, by standing on a normalised to 2nd–4th sec
lateral or medial wedges MVIC of a 4 sec
contraction
Karst and 12 asymp- M/F: 6/6 Isometric knee extension at 01 Surface electrode; SR 5 sec Isometric
Jewitt tomatic Age: 24.8
5.8 knee flexion. SLR to 25 cm in 500 Hz; FWR & isometric
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

(1993) Height: 01 knee flexion, with and LPF 15 Hz; phase of

178.0
10.1 without 451 external hip normalised to each
rotation. SLR to 25 cm in 01 maximum EMG exercise
knee flexion, with isometric hip obtained from any
adduction of the exercises

(Continued)
75
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76
Table 1. A summary of the studies included in this systematic review, investigating whether altering lower limb joint positioning can preferentially affect VMO elec-
tromyographic activity (Continued).

Population
characteristics Contraction
Sample size gender; mean and Electrode type; Period of type for
and SD age (years) and sampling rate; signal EMG EMG
Study diagnosis height (cm) Test procedures processing Analysis Analysis

Lam and 16 PFPS M/F: 5/11 Submaximal (60% MVC) SS at

Surface electrode; SR 2nd sec Isometric
Ng Age: 33.9
5.4 201 or 401 knee flexion, with
500 Hz; integrated of 3 sec
(2001) Height: N/D hip neutral; 451 hip external
but details not contraction
rotation; or 301 internal
stated;
rotation normalisation not
used
Laprade 9 PFPS PFPS Isometric knee extension with Surface electrode; SR Middle Isometric
et al 20 asymp- M/F: 0/9 knee at 601 flexion. Maximal 6 kHz; FWR but 1.5 sec
(1998) tomatic Age: 24.0
N/D isometric hip adduction with level of smoothing of a 6 sec
Height: knee flexed at 501 with and unclear; normalised contraction
165.8
N/D without isometric knee to levels during
Asymptomatic extension. Isometric tibial isometric knee
M/F: 0/20 medial rotation performed with extension at
Age: 24.0
N/D tibia at 301 external rotation, 50%MVC
Height: knee at 701 flexion, with and
165.6
N/D without isometric knee
extension
Livecchi 13 asymp- M/F:13/0 SLR to 401 hip flexion, and Surface electrode; SR Entire Isotonic
et al tomatic Age: 24.6
3.7 isotonic knee extension from 500 Hz; FWR & contraction
(2002) Height: 301 to 01 knee flexion in hip LPF 50 Hz; av (2 sec)
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

178.3
4.8 neutral; or maximum lateral EMG normalised to

rotation. All exercises peak EMG from
performed with an ankle same trial
weight 5% subject’s body
weight
Miller 6 PFPS PFPS SU-SD using a 6 inches high step, Surface electrode; SR For 4 sec on Isotonic
et al 9 asymp- M/F: 0/6 and SS to 751 knee flexion with 1020 Hz; processed 3rd, 8th
(1997a) tomatic Age: 20.8
2.3 hips in femoral and tibial by RMS, window and 13th
Height: size not stated; repetition
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165.6
5.8 neutral; 451 internal; and 451 normalised to of each

Asymptomatic external rotation MVIC exercise.
M/F: 0/9 Unclear
Age: 20.4
2.2 when in
Height: contraction
160.0
6.8 collected
Mirza- 8 asymp- M/F: N/D Isometric knee extension in 151 Indwelling electrode; Not docu- Isometric,
beigi tomatic Age: 26.5
4.2 knee flexion in neutral; hip in SR 2500 Hz; FWR mented Isokinetic
et al Height: N/D 301 internal; or 301 external and integration and
(1999) rotation. Full extension to full over 0.02 sec Isotonic
flexion knee isokinetic intervals;
extension with and without normalised to
valgus and varus knee force. MVIC
Full flexion to flexion
extension squat. Full flexion to
full extension squat with jump
Serrão 15 asymp- M/F: 10/5 Submaximal isometric knee Surface electrode; SR 2nd–4th sec Isometric
et al tomatic Age: 21.9
1.6 extension (at 10 rep max force 1000 Hz; processed of 4 sec
(2005) Height: N/D level) with 901 knee flexion by RMS, window contraction
against a horizontal leg press size unclear;
and tibia in maximum internal, normalised to
maximal external, or neutral MVIC
rotation
Tepper- 20 asymp- M/F: 11/9 Isometric knee extension at 01 hip Surface electrode; SR Plateau of Isometric
man tomatic Age: 22.8
2.7 and knee flexion with 100 Hz post- 7 sec
et al Height: N/D maximum ankle dorsiflexion, processing; HPF contraction
(1986) maximal plantarflexion, or 40 Hz; processed by
with the ankle in neutral RMS 33 ms
window; normali-
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

sation not used

Wild et al 18 PFPS M/F: 4/14 Isometric knee extension with 01 Surface electrode; SR Unclear Isometric
(1982) Age: 11–42 knee flexion and SLR with 01 not stated; no signal Isotonic
(range) knee flexion at 8 to 12 inches, processing;
Height: N/D with and without 5 pound integration carried
ankle weights in hip neutral; out manually by
internal; or external rotation planimetry
(Continued)
77
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78
Table 1. A summary of the studies included in this systematic review, investigating whether altering lower limb joint positioning can preferentially affect VMO elec-
tromyographic activity (Continued).

Population
characteristics Contraction
Sample size gender; mean and Electrode type; Period of type for
and SD age (years) and sampling rate; signal EMG EMG
Study diagnosis height (cm) Test procedures processing Analysis Analysis

Willis et al 18 PFPS PFPS Cycling on static bike with foot in Surface electrode; SR Mean of peak Isokinetic
(2005) 22 asymp- M/F: 9/9 tibial external rotation or not stated. Peak EMG
tomatic Age: 31.4
5.4 neutral EMG values used, extracted
Height: N/D but whether raw or from 4.5
Asymptomatic processed EMG is sec periods
M/F: 13/9 unclear; normalised at intervals
Age: 26.6
10.4 to peak EMG of 5, 10, 15,
Height: N/D during cycling at and 20 min
maximal resistance during
cycling
Zakaria 20 asymp- M/F: 0/20 Isometric knee extension with Surface electrode; SR 2nd–4th sec Isometric
et al tomatic Age: 24.0
2.0 knee at 01 flexion with and 2500 Hz: FWR & of 5–6 sec
(1997) Height: without maximal active LPF 6 Hz; contraction
166.0
7.0 dorsiflexion; isometric bilateral normalised to the
hip adduction (all with hip at control IKE
01 flexion/extension/rotation condition
and 101 abduction)

EMG: Electromyography; min: minutes; RMS: Root Mean Square

F: Female; MIC: Maximal Isometric Contraction; sec: seconds
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

FWR: Full Wave Rectification; msec: milliseconds; SLR: Straight Leg Raise
Hz: Hertz; mV: millivolts; SR: Sampling Rate
HPF: High Pass Filter; MVC: Maximal Voluntary Contraction; SS: Semi-squat
kHz: kiloHertz; MVIC: Maximum voluntary isometric contraction; SU-SD: step-up step-down
LPF: Low Pass Filter; N/D: Not Documented; SD: Standard Deviation
M: male; PFPS: Patellofemoral Pain Syndrome; WS-SD: walk stance-step down
 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
Of the 387 subjects, 133 were male, 232 female;
two studies did not specify gender (Gregersen,
Hull, and Hakansson, 2006; Mirzabeigi et al,
1999). The mean age of 353 subjects calculated
from 18 papers was 25.0 years (range 19.5–33.9
years); the papers by Wild, Franklin and Woods
(1982) and Bos and Blosser (1970) only specified
the age range. Mean height was 168.6 cm
(range 158.0–182.0); nine papers did not provide
this data (Bos and Blosser, 1970; Cerny, 1995;
Herrington et al, 2006; Lam and Ng, 2001;
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Mirzabeigi et al, 1999; Serrrão et al., 2005;
Tepperman, Mazliah, Naumann, and Delmore,
1986; Wild, Franklin, and Woods, 1982; Willis
et al, 2005). Surface EMG was conducted in 17
trials, with indwelling fine wire EMG used in
two studies (Cerny, 1995; Mirzabeigi et al, 1999).
Bos and Blosser (1970) used both surface and
indwelling electrodes.
The findings of the review are presented in
Tables 2–7. Six different lower limb anatomical
positions or co-contractions were identified to
assess for preferential VMO activity. These are
For personal use only.
presented below.
Hip adduction-abduction
As Table 2 demonstrates, eight studies were
reviewed assessing the effect of hip adduction or
abduction on VMO and VL activity (Bos and
Blosser, 1970; Cerny, 1995; Coqueiro et al, 2005;
Earl, Schmitz and Arnold, 2001; Hertel, Earl,
Tsang, and Miller, 2004; Hodges and Richard-
son, 1993; Karst and Jewett, 1993; Laprade,
Culham, and Brouwer, 1998). Bos and Blosser
(1970) assessed an altered lower limb joint
orientation, comparing EMG activity of a
quadriceps contraction in a neutral and an
abducted hip position. The other seven studies
assess EMG activity of a quadriceps contraction
with and without a hip adduction or abduction
co-contraction. Overall there was little evidence
of preferential VMO activation through hip
adduction or abduction. Hodges and Richard-
son (1993) observed that the addition of iso-
metric hip adduction produced statistically
significant increases in the non-normalised
VMO/VL ratio compared to the control con-
tractions without hip adduction (p < 0.05). For
the remaining seven studies, there was no evi-
dence of preferential VMO recruitment.
79
Hip internal-external rotation
Seven studies were identified assessing the
effect of altered hip rotation on VMO activity
(Cerny, 1995; Herrington et al, 2006; Karst and
Jewett, 1993; Lam and Ng, 2001; Livecchi et al,
2002; Mirzabeigi et al, 1999; Wild, Franklin, and
Woods, 1982). As Table 3 illustrates, in six
papers no statistically significant preferential
VMO activation was detected. One study, Lam
and Ng (2001), reported that during a semi-
squat isometric knee extension contraction at
401 of knee flexion, the VMO/VL ratio at
301 internal hip rotation was statistically sig-
nificantly greater than with lateral hip rotation
(p ¼ 0.03). However, the VMO/VL ratio with
internal hip rotation was not significantly
different from that with the hip in a neutral
position.
Tibial internal-external rotation
Four studies, shown in Table 4, assessed the
effect of tibial rotation on VMO and VL (Cerny,
1995; Laprade, Culham, and Brouwer, 1998;
Serrrão et al., 2005; Willis et al, 2005). Three
studies reported no statistically significant
difference in relative VMO and VL activity levels
with tibial internal or external rotation, com-
pared to neutral (Cerny, 1995; Laprade,
Culham, and Brouwer, 1998; Serrrão et al., 2005).
In contrast, Willis et al (2005) reported that
tibial external rotation significantly increased
VMO/VL ratio. Willis et al (2005) used external
tibial rotation during cycling. Laprade, Culham,
and Brouwer (1998) placed the foot in tibial
external rotation and then asked subjects to
internally rotate the tibia during isometric knee
extension. They reported a significantly greater
VMO/VL ratio in this exercise, compared to
internal tibial rotation alone, isometric knee
extension with hip adduction, or hip adduction
alone (p < 0.005). However, there was no sta-
tistically significant difference between tibial
internal rotation with isometric knee extension
compared to isometric knee extension alone.
Both Laprade, Culham, and Brouwer (1998) and
Willis et al (2005) normalised their EMG data,
but only presented VMO/VL ratio data, so the
actual levels of muscle activation remain
unclear. Willis et al (2005) analysed peak EMG
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80

Table 2. Results of papers reviewed assessing the effect of hip abduction-adduction co-contraction on EMG VMO activity.

Mean (SD) VMO Mean (SD) VL

activation (units activation (units Mean (SD)
EMG data are normalised % are normalised VMO/VL
Study management Task unless stated) % unless stated) ratio Conclusion (p value)
w w
Bos and 7 point amplitude Isom Ext 4 (2–6) 4 (2–6) N/D No preferential VMO
Blosser based scale Isom 4 (1–6)w 4 (2–6)w activation (p > 0.05)
(1970) Ext þ Abduction
Cerny (1995) Normalised % of QS Isom Ext 53 (26) 50 (23) 1.2 (0.5) No preferential VMO
MVIC QS Isom 56 (23) 52 (19) 1.1 (0.4) activation (p > 0.05)
Ext þ Adduction
Coqueiro Normalised % of Asymptomatic 16.14 (5.96) 22.64 (6.79) N/D No preferential VMO
et al (2005) MVIC Isom Ext in SS activation (p > 0.05)
Isom Ext in 35.6 (13.9) 39.6 (8.82)
SS þ Adduction
PFPS 26.96 (10.21) 35.53 (10.55)
Isom Ext in SS 34.96 (13.05) 41.45 (8.25)
Earl et al Normalised % of SS 29 (20) 28 (12) 1.02 (0.30) No preferential VMO
(2001) MVIC (left activation (p > 0.05)
limb)
Normalised % of SS þ Adduction 36 (20) 36 (10) 0.99 (0.44) No preferential VMO
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

MVIC (right activation (p > 0.05)

limb)
SS 27 (09) 26 (15) 1.28 (0.59)
SS þ Adduction 34 (10) 32 (14) 1.24 (0.53)
Hertel et al max integrated SS 1.25 (0.53) mV 0.42 (0.15) mV 3.00 (1.04) No preferential VMO
(2004) RMS EMG activation (p > 0.05)
(not
normalised)
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SS þ Adduction 0.96 (0.40) mV 0.37 (0.13) mV 2.58 (0.58)

SS þ Abduction 0.89 (0.31) mV 0.35 (0.13) mV 2.58 (0.43)
Hodges and RMS EMG (not SS 1.29 (0.40) Adduction enhanced
Richardson normalised) non-normalised VMO/
(1993) VL ratio (p < 0.05)
SS þ Adduction N/D N/D 2.80 (0.80)
Isok Ext 0.93 (0.30)
Isok 1.33 (0.60)
Ext þ Adduction
Karst and Normalised % of SLR 61.5 (14.5) 68 (21.5) N/D No preferential VMO
Jewett MVIC activation (p > 0.05)
(1993)
SLR þ Adduction 68 (12.0) 72 (24.0)
Laprade et al Normalised to Asymptomatic
(1998) 50% MVIC
Isom Ext N/D N/D 1.37 (0.08*) No preferential VMO
activation (p > 0.05)
Isom 0.92 (0.09*)
Ext þ Adduction
PFPS
Isom Ext 1.20 (0.09*)
Isom 1.00 (0.17*)
Ext þ Adduction
*
SEM: standard error of mean.
w
Median and range values for Bos and Blosser’s (1970) 7 point (0–6) amplitude based numerical rating scale to quantify EMG activity.
EMG: Electromyography; iEMG: integrated EMG; Isok. Ext: isokinetic Extension
Isom Ext: Isometric Knee Extension; max: maximum; mV: millivolts
MVIC: Maximum voluntary isometric contraction; N/D: Not Documented; RMS: Root Mean Square
SD: Standard Deviation; SLR: Straight Leg Raise; SS: Semi-squat
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
81
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82
Table 3. Results of papers reviewed assessing the effect of hip rotation on EMG VMO activity.

Mean (SD) Mean (SD)

VMO VL
activation activation
(units are (units are
normalised normalised Mean (SD)
EMG % unless % unless VMO/VL
Study analysis Task stated) stated) ratio Conclusion (p value)

Cerny Normal- QS Isom Ext 53 (26) 50 (23) 1.2 (0.5)

(1995) ised %
of
MVIC
QS Isom Ext þ Internal Rotation 53 (28) 46 (22) 1.2 (0.5) No preferential VMO
activation (p > 0.05)
QS Isom Ext þ External Rotation 48 (27) 48 (24) 1.1 (0.6)
Isok Ext 34 (18) 35 (15) 1.1 (0.4)
Isok Ext þ Internal Rotation 28 (16) 28 (13) 1.2 (0.5)
Isok Ext þ External Rotation 22 (12) 26 (12) 1.0 (0.4)
Herrington Normal- Eccentric
et al ised %
(2006) of
MVIC
Isok Ext 23.3 (17) 28.8 (14.2) N/D No preferential VMO
activation (p ¼ 0.33)
Isok Ext þ Internal Rotation 27.6 (17.7) 34.7 (17.7)
Isok Ext þ External Rotation 25.7 (17.2) 35.9 (19.6)
SS 17.5 (16.9) 15.4 (8.1)
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

SS þ Internal Rotation 17.5 (16.0) 16.1 (10.8)

SS þ External Rotation 17.8 (16.3) 17.9 (11.5)
Concentric 34.7 (14.4) 50.5 (25.8)
Isok Ext 34.3 (15.9) 44.4 (22.2)
Isok Ext þ Internal Rotation 34.3 (20.3) 42.6 (24.5)
Isok Ext þ External Rotation 25.7 (13.6) 26.0 (14.4)
SS 27.0 (17.2) 27.4 (12.2)
SS þ Internal Rotation 26.3 (17.7) 28.7 (17.5)
SS þ External Rotation
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Karst and Normal- SLR 61.5 (29) 68.0 (43) N/D No preferential VMO
Jewett ised % activation (p > 0.05)
(1993) of
MVIC
SLR þ External Rotation 51.0 (48) 60.0 (42)
Lam and iEMG (not In 201 knee flexion:
Ng normal-
(2001) ised)
Isom Ext N/D N/D 0.89 At 40 knee flexion, internal
rotation increases VMO/VL
ratio compared to external
rotation (p ¼ 0.03), but not
significantly different to
neutral rotation (p > 0.05)
Isom Ext þ Internal Rotation 0.91
Isom Ext þ External Rotation 0.90
In 401 knee flexion:
Isom Ext 0.92
Isom Ext þ Internal Rotation 0.97
Isom Ext þ External Rotation 0.87
Livecchi et Mean SLR 5.2 (2.4*) 2.7 (3.7*) 1.50 (0.44*)
al (2002) EMG of
10 trials
(average
EMG
normal-
ised to
peak
during
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

same
trial)
SLR þ External Rotation 4.8 (1.9*) 2.8 (3.6*) 1.40 (0.38*) No preferential VMO
activation (p ¼ 0.62)
Isok Ext 4.3 (0.2*) 2.6 (3.8*) 1.29 (0.32*)
Isok Ext þ External Rotation 4.5 (1.8*) 2.6 (4.3*) 1.41 (0.36*)

(Continued)
83
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84
Table 3. Results of papers reviewed assessing the effect of hip rotation on EMG VMO activity (Continued).

Mean (SD) Mean (SD)

VMO VL
activation activation
(units are (units are
normalised normalised Mean (SD)
EMG % unless % unless VMO/VL
Study analysis Task stated) stated) ratio Conclusion (p value)

Mirzabeigi Normal- Isom Ext 100 129 N/D No preferential VMO

et al ised % activation (p > 0.05)
(1997) of
MVIC
Isom Ext þ Internal Rotation 85 108
Isom Ext þ External Rotation 68 96
Wild et al Manual SLR N/D N/D No preferential VMO
(1982) integra- activation (no p value)
tion
SLR þ Internal Rotation Unclear
SLR þ External Rotation
*
SEM: standard error of mean.
EMG: Electromyography; iEMG: integrated EMG; Isok Ext: Isokinetic Extension
Isom Ext: Isometric Knee Extension; max: maximum; MVC: Maximum voluntary contraction
MVIC: Maximum voluntary isometric contraction; N/D: Not Documented; RMS: Root Mean Square
SD: Standard Deviation; SLR: Straight Leg Raise; SS: Semi-squat
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
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Table 4. Results of papers reviewed assessing the effect of tibial rotation on EMG VMO activity.

Mean (SD)
Mean (SD) VL
VMO activation
activation (units are
(units are normalised Mean (SD)
EMG normalised % % unless VMO/VL
Study analysis Task unless stated) stated) ratio Conclusion (p value)

Cerny Normalised Isom Holds 5 (4) 7 (6) N/D No preferential VMO

(1995) % of activation (p > 0.05)
MVIC
Isom Holds þ Internal 6 (4) 8 (5)
Rotation
Isom Holds þ External 5 (4) 8 (6)
Rotation
Laprade Normalised Asymptomatic
et al to 50% Isom Ext N/D N/D 1.37 (0.08*) VMO/VL ratio during
(1998) MVIC Isom Ext with internal
tibial rotation is not
statistically significantly
different to Isom ext alone
(p > 0.05), but both show
greater VMO/VL ratios
compared to other tested
exercises (p < 0.005),
Isom Ext þ Isom 1.50 (0.11*)
internal rotation
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

PFPS
Isom Ext 1.20 (0.09*)
Isom Ext þ Isom 1.42 (0.15*)
internal rotation

(Continued)
85
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86
Table 4. Results of papers reviewed assessing the effect of tibial rotation on EMG VMO activity (Continued).

Mean (SD)
Mean (SD) VL
VMO activation
activation (units are
(units are normalised Mean (SD)
EMG normalised % % unless VMO/VL
Study analysis Task unless stated) stated) ratio Conclusion (p value)

Serrão et al Normalised Isom Ext 46.2 (3.2) 50.2 (3.4) N/D No effect on VMO activation
(2005) % of Isom Ext þ Internal 49.0 (3.5) 54.1 (3.4) (p ¼ 0.26), but int rotation
MVIC Rotation 47.3 (3.3) 51.0 (3.6) increased VL activity
Isom Ext þ External significantly (p ¼ 0.005)
Rotation
Willis et al Normalised Asymptomatic
(2005) average
peak
EMG as
% of
peak
values at
max
resistance
Cycle þ Neutral N/D N/D 1.01 (0.23) External Rotation enhances
VMO/VL ratio
(p ¼ 0.0001)
Cycle þ External 1.47 (0.46)
Rotation
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

PFPS
Cycle þ Neutral 1.03 (0.27)
Cycle þ External 1.89 (0.99)
Rotation

*SEM: standard error of mean.

EMG: Electromyography; iEMG: integrated EMG; Isom Ext: Isometric Knee Extension
Max: maximum; MIC: Maximum Isometric Contraction; N/D: Not Documented
SD: Standard Deviation; RMS: Root Mean Square
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Table 5. Results of papers reviewed assessing the effect of a combined femoral-tibial rotation on EMG VMO activity.

Mean (SD)
EMG Mean (SD) Mean (SD) VMO/VL
Study analysis Task VMO VL ratio Conclusion (p value)

Bos and 7 point Isom Ext 4 (2–6)w 4 (2–6)w N/D No preferential VMO
Blosser amplitude activation (p > 0.05)
(1970) based scale
Isom Ext þ External 5 (2–6)w 4 (1–6)w
Rotation and ankle
dorsiflexion
Miller et al Normalised Asymptomatic
(1997a) % of SS N/D N/D 2.08 (1.14) In controls (but not PFPS),
MVIC internal rotation
increased VMO/VL ratio
compared to external
rotation (p < 0.01), but
was not significantly
different to neutral
rotation (p > 0.05)
SS þ Internal Rotation 2.35 (1.47)
SS þ External Rotation 1.85 (1.27)
SU-SD 2.18 (1.37)
SU-SD þ Internal Rotation 2.29 (1.41)
SU-SD þ External Rotation 1.67 (1.20)
PFPS
SS 0.91 (0.45)
SS þ Internal Rotation 0.87 (0.45)
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

SS þ External Rotation 1.16 (0.57)

SU-SD 0.80 (0.25)
SU-SD þ Internal Rotation 0.94 (0.36)
SU-SD þ External Rotation 1.02 (0.57)
w
Median and range values for Bos and Blosser’s (1970) 7 point (0–6) amplitude based numerical rating scale to quantify EMG activity.
EMG: Electromyography; N/D: Not Documented; RMS: Root Mean Square
SS: Semi-squat; SU-SD: Step-Up Step-Down; SD: Standard Deviation
87
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88

Table 6. Results of papers reviewed assessing the effect of ankle position on EMG VMO activity.

Mean (SD) VMO Mean (SD) VL

activation (units activation (units Mean (SD)
are normalised % are normalised % VMO/VL Conclusion
Study EMG analysis Task unless stated) unless stated) ratio (p value)

Cerny Normalised % Isom Ext 53 (26) 50 (23) 1.2 (0.5) No preferential

(1995) of MVIC VMO
activation
(p > 0.05)
Isom Ext þ Dorsiflexion 58 (24) 52 (21) 1.2 (0.4)
Isom 52 (24) 50 (27) 1.2 (0.5)
Ext þ Plantarflexion
Tepperman Mean EMG Isom Ext 64.6 mV (SD N/D) 77.6 mV N/D No preferential
et al RMS VMO
(1986) activation
(p > 0.05)
Isom Ext þ Dorsiflexion 69.0 mV 82.9 mV
Isom 68.8 mV 79.8 mV
Ext þ Plantarflexion
Zakaria et al % of Isom Ext Isom Ext 100 100 N/D No preferential
(1997) control VMO
condition activation
(p > 0.05)
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

Isom Ext þ Dorsiflexion 121 (60)% * 116 (40) %*

*
These values are percentage of the control condition (without dorsiflexion).
iEMG: integrated EMG; mV: millivolt seconds; Isomet Ext: Isometric Knee Extension
N/D: Not Documented; max: maximum; RMS: Root Mean Square
SD: Standard Deviation; mV: microvolt
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Table 7. Results of papers reviewed assessing the effect of foot or ankle position on EMG VMO activity.

Mean (SD) VMO Mean (SD) VL Mean

activation (units are activation (units are (SD)
EMG normalised % unless normalised % unless VMO/VL Conclusion
Study analysis Task stated) stated) Ratio (p value)

Cerny Normalised WS-SD þ subtalar N/D N/D 1.3 (0.2) No preferential

(1995) % of neutral VMO activation
MVIC (p > 0.05)
WS-SD þ subtalar 1.1 (0.4)
supination
WS-SD þ subtalar 1.0 (0.4)
pronation
Gregersen Unclear Cycling N/D N/D Unclear Pronation increases
et al VMO/VL ratio
(2006) (p < 0.0001)
Cycling þ Supination
Cycling þ Pronation
Hung and Normalised Isom Ext 1.00 (0) 1.00 (0) 1.02 (0)
Gross % of
(1999) MVIC
Isom 0.99 (1.28) 0.99 (1.11) 1.07 (0.32) No preferential
Ext þ supination VMO activation
(p > 0.05)
Isom 0.98 (1.10) 1.00 (1.30) 0.98 (0.12)
Ext þ pronation
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

SS 0.47 (0.17) 0.40 (0.20) 1.31 (0.33)

SS þ supination 0.45 (0.18) 0.38 (0.18) 1.26 (0.38)
SS þ pronation 0.45 (0.21) 0.40 (0.27) 1.20 (0.23)

iEMG: integrated EMG; Isom Ext: Isometric Knee Extension; max: maximum
MVIC: Maximum voluntary isometric contraction; N/D: Not Documented ; SD: Standard Deviation
SS: Semi-squat; WS-SD: walk stance-step down
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 90 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
values rather than integrated EMG, which is
more commonly used.
Combined tibial/femoral internal-
external rotation
One study evaluated the effect of combined
tibial and femoral rotation on the VMO/VL
activity ratio (Miller, Sedory, and Croce, 1997a),
whilst Bos and Blosser (1970) assessed the VMO
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and VL EMG activity with combined tibial/
femoral external rotation and ankle dorsiflexion.
As Table 5 summarises, Miller, Sedory, and
Croce (1997a) reported no significant difference
in the VMO/VL activity ratio in subjects with
patellofemoral pain syndrome. Conversely, in
this study, asymptomatic subjects demonstrated
an increased VMO/VL activity ratio at 451
combined tibial and femoral internal rotation, in
comparison to 451 tibial and femoral external
rotation whilst performing a step-up, step-down
or semi-squat exercise (Miller, Sedory, and
For personal use only.
Croce, 1997a). However, this was not sig-
nificantly different from performing these
activities in neutral tibial and femoral rotation
(p > 0.05). Bos and Blosser (1970) reported that
no statistically significant preferential VMO
activation was detected in their external rotation
limb position, compared to neutral.
Ankle dorsiflexion/plantarflexion
Three studies assessed the effect of ankle
position on the VMO/VL activity ratio (Cerny
1995; Tepperman, Mazliah, Naumann, and
Delmore, 1986; Zakaria, Harburn, and Kramer,
1997). As outlined in Table 6, these studies
reported no significant evidence that VMO
could be preferentially activated by altering
ankle joint position during quadriceps exercises.
Foot pronation/supination
Table 7 presents the findings of three studies
that assessed the effect of altered foot posi-
tion on VMO and VL activity (Cerny, 1995;
Gregersen, Hull, and Hakansson, 2006; Hung
and Gross, 1999). Both Hung and Gross (1999)
and Cerny (1995) reported that altering foot
position does not significantly preferentially
recruit VMO over VL. Gregersen, Hull, and
Hakansson (2006) reported that during a cycling
task when the foot was positioned in pronation,
the VMO/VL activity ratio was significantly
greater in comparison to neutral or supinated
foot positions (p < 0.0001). Although the results
indicate that increasing foot pronation produced
changes in knee moments that were significantly
correlated with VMO/VL ratio changes, the
paper does not provide sufficient EMG data for
detailed analysis and clinical interpretation.
Critical appraisal
Following the CASP appraisal (Table 8), the
methodological quality of the present evidence-
base may be questioned. All studies, with the
exception of Bos and Blosser (1970) and Wild,
Franklin, and Woods (1982), clearly identified
their research question and used an appropriate
prospective observational study design. No
study clearly identified the method of partici-
pant recruitment. The studies reviewed fre-
quently provided age, gender, and height data
(Table 1) but poorly acknowledged: (1) the level
of sporting participation of their sample and (2)
how informed or knowledgeable their subjects
were with respect to the study’s aims and
objectives. Of those studies recruiting subjects
with patellofemoral disorders, none identified
the duration of their cohort’s patellofemoral
pain, or whether the tasks under examination
aggravated symptoms during testing. No study
justified their sample size using a power calcu-
lation, which ranged from just 8 (Hertel, Earl,
Tsang, and Miller, 2004; Mirzabeigi et al, 1999)
to 43 participants (Herrington et al, 2006).
The papers reviewed clearly identified their
study procedures anod the methods of testing.
However, all studies poorly described electrode
positioning, largely stating that electrodes were
placed ‘‘over the muscle belly’’ (Cerny, 1995;
Gregersen, Hull, and Hakansson, 2006; Hodges
and Richardson, 1993; Hung and Gross, 1999;
Karst and Jewett, 1993; Lam and Ng, 2001;
Laprade, Culham, and Brouwer, 1998; Serrrão
et al., 2005; Willis et al, 2005; Zakaria, Harburn,
and Kramer, 1997). All studies, except Willis
et al (2005) and Tepperman, Mazliah, Naumann,
and Delmore (1986), clearly detailed study
findings, appropriately relating their results to
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Table 8. A summary of the CASP results.

Bos Gre- Hung Hodges Karst Lam

and Coqueiro Earl gersen Hertel and and and and Laprade Miller Mirzabeigi Serrao Tepperman Wild Willis Zakaria
Blosser Cerny et al et al et al Herrington et al Gross Richardson Jewett Ng et al Livecchi et al et al et al et al et al et al et al
CASP factors (1970) (1995) (2005) (2001) (2006) (2006) (2004) (1999) (1993) (1993) (2001) (1998) (2002) (1997a) (1997) (2005) (1986) (1982) (2005) (1997)

Clearly focused N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y
question
stated
Appropriate N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
design
Appropriate N N N N N N N N N N N N N N N N N N N N
recruitment
Operation N Y Y Y Y Y Y Y Y Y Y Y N Y N Y Y N Y Y
clearly
defined
Appropriate N Y Y Y Y Y N/C Y Y Y Y Y Y Y Y Y N N Y Y
outcomes
used
Confounding N N N N N N N N N N N N N N N N N N N N
factors
identified
Confounding N N N N N N N N N N N N N N N N N N N N
factors
accounted
Greater than Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
85% of the
sample on
final follow-
up
Suitable Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
duration of
follow-up
Precise N N N N N N N N N N N N N N N N N N N N
statistical
results
presented
Appropriate Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y
interpreta-
tion
Possible bias N N N N N N N N N N N N N N N N N N N N
acknowl-
Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98

edged
Ability to N Y N N N N N N N N N Y N N N N N N N N
generalise
results
Interpretation Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y N Y N N
related to
the existing
evidence

Y: yes; N: no; N/C: not clear

91
 92 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
the existing evidence-base. Although all papers
except Wild, Franklin, and Woods (1982)
assessed their data using inferential statistics,
principally undertaking an analysis of variance,
no studies acknowledged whether their data
were normally distributed or provided confidence
interval data (Bland, 2006).
Discussion
Physiother Theory Pract Downloaded from informahealthcare.com by Serials Unit - Library on 11/17/12
This review aimed to determine whether
the VMO could be preferentially activated
by altering lower limb joint position or
co-contraction. The findings of our review of
387 subjects from 20 studies suggest that altering
lower limb joint orientation or the addition of
lower extremity co-contraction does not pre-
ferentially enhance activation of VMO over VL.
Therefore, physiotherapists should not attempt
to focus primarily on the VMO as traditionally
recommended, because such exercises may be
futile in enhancing VMO activity. A small
For personal use only.
number of studies were identified, suggesting
that VMO may be preferentially activated by
performing quadriceps exercises with hip
adduction (Hodges and Richardson, 1993), or in
tibial external rotation (Willis et al, 2005) or foot
pronation (Gregersen, Hull, and Hakansson,
2006). Following a critical appraisal of the
methodological rigour of this evidence-base, a
number of methodological limitations were
identified. Many studies poorly described sub-
ject characteristics, or the methods and source of
recruitment, limiting generalisablility of study
findings to the clinical setting. The majority of
papers evaluated small, underpowered samples,
permitting the possibility of a type II error
(Portney and Watkins, 2000). The papers
reviewed poorly described electrode placement,
thereby questioning the reliability of the data
collected, whilst making the accurate replication
of these studies very difficult (Kollmitzer,
Ebenbichler, and Kopf, 1999). The poor
description of electrode placement, particularly
in those papers that described electrode place-
ment on the distal portion of the VM (Bos and
Blosser, 1970; Tepperman, Mazliah, Naumann,
and Delmore, 1986), means that the vastus
medialis longus (VML) may have been assessed
as opposed to VMO. Where patellofemoral pain
syndrome patients were recruited, no study
documented the duration of subject’s patellofe-
moral joint pain, or whether during the test
procedures, their pain was aggravated. Previous
studies have acknowledged that pain may
influence normal EMG activity (Le Pera et al,
2001; Rutherford, Jones, and Newham, 1986),
and this may have accounted for intrasample
and between-group differences. No articles
recorded the precision of their statistical results
with confidence intervals, a major limitation in
data analysis and interpretation, particularly
when attempting to infer what findings mean
clinically (Bland, 2006). Consequently, any con-
clusions formulated from the present evidence-
base must be viewed with caution.
Of the three papers that reported that altering
lower limb joint position or co-contraction could
preferentially activate VMO, only Hodges and
Richardson’s (1993) study assessed a ‘‘tradi-
tional’’ quadriceps exercises, whilst the other
two were evaluated during cycling (Gregersen,
Hull, and Hakansson, 2006; Willis et al, 2005).
In these studies, a number of EMG limitations
were observed. Hodges and Richardson (1993)
did not normalise their EMG data, and hence it
is unclear whether the contractions generated
were intense enough to elicit a training effect,
and how the raw EMG differences (in volts)
equate to relative differences (in percentage
maximal activity). Willis et al (2005) did not
report EMG processing methods (if any were
used) such as filtering to remove possible
movement artefacts, and level of smoothing.
They also evaluated the mean of peak EMG
values obtained, rather than the more common
integrated EMG. They also did not report the
actual levels of normalised muscle activation
(e.g., 20% or 70% of maximum), so interpreta-
tion of the results is limited.
Other studies provided evidence that changes
in joint orientation may also affect levels of
muscle activation in VMO and VL, but not in
the preferred direction. Three studies observed
exercises that did not produce VMO activity
greater than the control condition, but which
were significantly different to other lower limb
positions. These included hip external/internal
rotation (Lam and Ng, 2001) and external
femoral and tibial rotation combined (Miller,
Sedory, and Croce, 1997a). Serrrão et al. (2005)
reported that internal tibial rotation increased
both VMO and VL activation, but only VL
 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
reached a statistically significant increase (p ¼
0.03). Laprade, Culham, and Brouwer (1998)
reported that isometric quadriceps contraction
and hip adduction, and internal tibial rotation
alone, produced relatively greater levels of VL
EMG activity than VMO. Accordingly, clin-
icians should be aware of lower limb orientation
as certain positions may increase VL activation
or reduce VMO activation, and theoretically
lateralise the patella further (Grelsamer, 2000).
The clinical relevance, with regard to training
Physiother Theory Pract Downloaded from informahealthcare.com by Serials Unit - Library on 11/17/12
effect for actual muscle strengthening, remains
unclear. No paper stated whether the size of the
preferential recruitment was clinically significant.
Whilst Tables 2–7 suggest that there may not be
many statistically significant differences in VMO/
VL ratio between the papers, a number of studies
reported a nonsignificant increase in mean VMO/
VL values. For instance, Laprade, Culham, and
Brouwer (1998) reported an increased mean VMO/
VL value when isometric quadriceps contraction
was combined with tibial internal rotation, com-
pared to isometric quadriceps alone. Whether
For personal use only.
these increases could be clinically or physiologi-
cally important in strengthening or re-education
remains unclear.
Clinically, muscle onset timing has been iden-
tified as a potential aetiological factor for patello-
femoral disorders (Chester et al, 2008; Powers,
1998; Thomee, Augustsson, and Karlsson, 1999).
A delay in activation of the VMO relative to
VL may exist in patellofemoral pain syndrome
(Cowan et al, 2001; Voight and Wieder, 1991).
Activities, referred to as preferential VMO exer-
cises, have been advocated to produces changes in
muscle activation timing of VMO and VL via
motor re-learning or re-education (McConnell,
1986; McConnell, 1996). This review did not
assess EMG onset timing, but it did assess the
evidence for preferential activation and hence
strengthening of VMO. Further study may be
indicated to determine if quadriceps contractions
performed in specific lower limb positions can
influence VMO and VL onset timing to perform
in the rehabilitation of this suggested dysfunction.
Hypotheses have been proposed to explain
why the VMO may be enhanced by altering
lowering limb position, or though co-contraction.
It has been speculated that altering joint position
could change the length-tension capabilities of
surrounding muscles, to influence physiological
advantage and required level of activation (Lam
93
and Ng, 2001). For instance, the rational for
hip adduction co-contraction is that some VMO
fibres originate from the distal position of the
adductor magnus; therefore, activating this
muscle may impact upon VMO function (Brunet
and Stewart, 1989; Cerny, 1995; Rice, Bennett,
and Ruhling, 1995). However, controversy exists
regarding the natural anatomical variance of the
distal VM (Barbaix and Pouders, 2005; Nozic,
Mitchell, and de Klerk, 1997). Although the
literature would suggest that there is an increased
obliquity of muscle fibre alignment more distally,
the presence of a fibrofascial plane and the
innervation of the VM may vary between indivi-
duals (Amis and Farahmand, 1996; Barbaix and
Pouders, 2005; Lieb and Perry, 1968; Terry,
1989). Therefore, it may not be possible to gene-
ralise how the VMO functions in all subjects
given this variability in morphology. The findings
of this review would question the functional
relevance of this theoretical speculation.
Cross-talk is a possible issue to consider when
reviewing EMG research. Cross-talk can be
described as an EMG signal generated from
muscles other than the muscle of interest, thereby
contaminating the EMG by volume conduction
and so affect interpretation (Koh and Grabiner
1992). In the studies in this review, cross-talk
could theoretically be generated from the other
quadriceps muscles or from the hip adductors.
The amount of cross-talk is dependent on various
factors such as electrode size, detection depth,
interelectrode distance, and placement, factors
that differ between studies. It is generally pre-
sumed that cross-talk between the four quadriceps
heads is negligible. Winter (1991) reported that a
spacing of 4 cm between electrode pairs on rectus
femoris and either VMO or VL could produce
cross-talk of 6% or less between muscles. With
regard to cross-talk from the hip adductors, it is
notable the Cerny (1995) reports data showing no
increase in VMO activity when adductor magnus
is activated, therefore indicative of minimal, if
any, cross-talk. Similarly, Hodges and Richardson
(1993) also carried out pilot work indicating
cross-talk from hip adductors was ‘‘minimal.’’
Hypothetically, however, the significant results of
Hodges and Richardson (1993) could possibly be
due to cross-talk from the hip adductors detected
on VMO during adduction.
Two studies in this review assessed the EMG
activity of the VM, although not specifically
 94 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
termed VMO (Bos and Blosser, 1970; Tepperman,
Mazliah, Naumann, and Delmore, 1986). How-
ever, because electrode placement was poorly
described, it remains unclear whether VMO or
VML was assessed in these papers. Some debate
exists to the existence of the VMO as a separate
muscle, citing cadaver studies that have been
unable to identify a difference in muscle fibre
alignment between the proximal and distal VM
to differentiate VMO from VML (Hubbard,
Sampson, and Elledge, 1997; Hubbard, Sampson,
Physiother Theory Pract Downloaded from informahealthcare.com by Serials Unit - Library on 11/17/12
and Elledge, 1998; Ono et al, 2005). However,
other studies have identified differences in mor-
phology between the VMO and VML in respect
to fibre architecture and neurovasculature, which
may account for differences in EMG activity
between these two components of VM (Lieb and
Perry, 1968; Özer et al, 2004; Toumi et al, 2007).
Because of this uncertainty, the inclusion of
EMG results of the distal portion of the VM is
warranted. However, because VML’s role has
been described as a knee extensor, as opposed to
VMO as a medial patellar stabiliser, the accurate
For personal use only.
electrode placement on the VMO or most distal
VM fibres is important to ensure any changes in
EMG (indicative of preferential activity) are
definitely from VMO not VML, and to prevent
cross-talk from VML being attributed to VMO
(Byrne et al, 2005).
A number of papers were initially identified,
which related to the research question but were
excluded in our final review. For instance, a
number of papers did not compare a quadriceps
contraction to a quadriceps contraction in a
different lower limb joint position (Hanten and
Schulthies, 1990; Miller, Sedory, and Croce, 1997b;
Monteiro-Pedro, Vitti, Bérzin, and Bevilaqua-
Grosso, 1999). Similarly, some studies assessed
EMG activity of the vastii in different lower limb
orientations, but did not directly compare their VL
to VM EMG activity results in relation to each
other (Gough and Ladley, 1971; Hasler, Denoth,
Stacoff, and Herzog, 1994; Kongsgaard et al,
2006; Ninos, Irrgang, Burdett, and Weiss, 1997;
O’Sullivan and Popelas, 2005; Signorile et al,
1995; Yamashita, 1988). By adhering to our
predetermined selection criteria we were able
to answer our research question, although this
meant incorporating fewer studies than initially
anticipated.
Many studies recruited asymptomatic subjects
or subjects with patellofemoral pain syndrome. It
is therefore not possible to state whether the
findings from this study are generalisable to
patellar instability populations. Furthermore, as
the studies reviewed poorly described their
subject’s characteristics, it remains difficult to
comment on whether the severity of patello-
femoral pain syndrome symptoms or the hetero-
geneity in diagnosis between these samples
influenced results. Further study is advocated to
assess whether lower limb orientation can influ-
ence VMO activity in a population with clearly
defined patellofemoral pain syndrome or patellar
instability.
Andriacchi, Anderson, Örtengren, and Mikosz
(1984), Boucher, King, Lefebvre, and Pépin
(1992), Tang et al (2001), and Taskiran
et al (1998) suggested that the degree of knee
flexion may have an important role in vastus
medialis, VMO and VL recruitment in patellofe-
moral pain syndrome populations. As Table 1
demonstrates, the range of knee flexion varied
between studies. Lam and Ng (2001) reported
that at 401 of knee flexion, internal rotation
enhances VMO compared to VL, but that this
was not the case at 201 of flexion. Similarly,
Tang et al (2001), and Basmajian, Harden, and
Regenos (1971) purported that the VMO is
maximally activated at 601 degrees of knee
flexion, speculating that any VMO exercises
irrespective of lower limb joint orientation should
be performed at this degree of knee flexion.
Accordingly, this further variable may account
for the differences in VMO and VL activity
between the papers reviewed where knee joint
angulation differed, introducing an additional
source of heterogeneity between these studies.
As suggested above, there was considerable
heterogeneity between the 20 papers reviewed.
This may have accounted for differences in EMG
results within the review. Because of this hetero-
geneity, it was inappropriate to assess these
findings as a meta-analysis. Such sources of
heterogeneity include population characteristics
in respect to age, height, sporting participation,
history of knee pathology, knee diagnosis, and
duration of possible symptoms. A considerable
source of heterogeneity was study methodology.
Each study design presented with differences in
respect to EMG electrode placement, equipment,
sampling rate and signal processing, and data
manipulation such as normalisation; all these
factors may have a significant impact on the
 Smith et al. /Physiotherapy Theory and Practice 25 (2009) 69–98
reliability, validity, and generalisability of the
EMG results (Kollmitzer, Ebenbichler, and
Kopf, 1999; Mathur, Eng, and MacIntryre, 2005;
Weiss, Silver, and Weiss, 2004; Yamada and
Demura, 2005). Furthermore, inconsistency of
results may be associated to the differing EMG
methods used to assess and analyse VMO and VL
(Herrington et al, 2006; MacGregor, Gerlach,
Mellor, and Hodges, 2005). Specifically in the
assessment of lower limb orientation, Callaghan,
McCarthy, and Oldham (2007), Herrington and
Physiother Theory Pract Downloaded from informahealthcare.com by Serials Unit - Library on 11/17/12
Pearson (2006), Herrington et al (2006), Rainoldi
et al (2008), and Wong and Ng (2006) questioned
whether inconsistency in electrode placement,
level of loading, maintaining limb position, test
angular velocity, subject characteristics, and
normalisation could all influence data collection
and the interpretation of final results. For
example, Livecchi et al (2002) extracted the
average EMG for contractions and normalised
these to the peak EMG values during the same
trial, producing normalised VM and VL EMG
values below 10%. This may not affect VMO/VL
For personal use only.
ratio comparisons between exercises, but it does
make comparisons with other studies difficult.
Although every effort was made to limit
research bias or error from this systematic
review, two potential limitations were identified.
First, the review only assessed published mate-
rial and excluded university theses and unpub-
lished sources of data, ensuring that the studies
reviewed had been assessed through peer-review,
to attempt to maintain quality. However, it
meant that our findings may have been influ-
enced by publication bias (Rothstein, Sutton,
and Borenstein, 2005; Song et al, 2000). Second,
non-English language papers were excluded
from this review because of the costs of trans-
lation, but limiting the scope of the review.
Conclusion
This review suggests that VMO cannot be
preferentially activated by altering lower limb
joint orientation or through the addition of
co-contraction. Only three of the 20 studies
included provided any evidence for preferential
VMO activation, each in different lower limb
joint positions. Furthermore, a number of
methodological limitations, particularly in EMG
data collection and analysis, were identified in
95
these studies. Strong evidence that VMO can be
preferentially activated and strengthened is
absent. It is therefore recommended that clin-
icians should not focus on VMO strengthening,
in preference to general quadriceps training
when rehabilitating patients with patellofemoral
disorders, because this may not be possible.
Acknowledgements
We thank the library staff at the Norfolk and
Norwich University Hospital’s Sir Benjamin
Gooch Library for their assistance in gathering
the articles used in this paper.
Declaration of interest: The authors report no con-
flicts of interest. The authors alone are responsible
for the content and writing of the paper.
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