ACL Injury Mechanisms and The Kinetic Chain Linkage: The Effect of Proximal Joint Stiffness On Distal Knee Control During Bilateral Landings

ACL Injury Mechanisms and the Kinetic Chain Linkage: The Effect of Proximal Joint
Stiffness on Distal Knee Control during Bilateral Landings
Jordan Cannon *✝, MSc, Edward DJ Cambridge✝, BKin, PhD(c), and Stuart M McGill ✝, PhD
* Current: Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and

Physical Therapy, University of Southern California, Los Angeles, California, US
✝ Worked performed at: Spine Biomechanics Laboratory, Department of Kinesiology,

University of Waterloo, Waterloo, Ontario, Canada
Support: Natural Sciences and Engineering Research Council of Canada

Downloaded from www.jospt.org by La Trobe University on 07/21/19. For personal use only.
Review Board: University of Waterloo Office of Research Ethics
Corresponding Author:
Jordan Cannon
Email: cannonjo@usc.edu
Musculoskeletal Biomechanics Research Laboratory,
J Orthop Sports Phys Ther
Division of Biokinesiology and Physical Therapy,

University of Southern California, Los Angeles, California, US
22 ACL Injury Mechanisms and the Kinetic Chain Linkage: The Effect of Proximal Joint
23 Stiffness on Distal Knee Control During Bilateral Landings
24 Abstract
25 Study Design: Cross-sectional
26 Objective: To investigate the influence of lumbar spine joint rotational stiffness (JRS), and
27 gluteal musculature contribution to hip JRS, on dynamic knee valgus.
28 Background: Neuromuscular deficits at the trunk and hip may contribute to dynamic knee
29 valgus and ACL injury mechanisms. However, comprehensive examination of neuromuscular
30 patterns and their mechanical influence are lacking.

31 Methods: Eighteen university-aged women completed a drop vertical jump while we measured
32 kinematics, kinetics, and twenty-four channels of electromyography spanning the trunk and hip
33 musculature. We classified each limb as high or low valgus based on frontal plane knee
34 displacement magnitude. We used anatomically-detailed EMG-driven biomechanical models to
35 quantify lumbar spine JRS and muscle contributions to hip JRS.
36 Results: Low valgus limbs generated greater gluteus medius frontal JRS (p=0.002, ES=1.3) and
37 gluteus maximus transverse JRS (p=0.003, ES=1.2) compared to high valgus limbs. Participants
38 with bilateral high valgus collapse had substantially reduced lumbar spine sagittal JRS compared
39 to the group with low valgus on both limbs (p=0.05, ES=5.1). Those who displayed low valgus
40 on both limbs also displayed a peak lumbar spine flexion angle of 24 ± 4o compared to the
41 bilateral high valgus group’s angle of 38 ± 10o (p=0.09, ES=1.8).
1
42 Conclusion: This is the first work of its kind to specifically characterize lumbar spine and hip
43 neuromuscular mechanisms that may be responsible for dynamic valgus in a drop vertical jump,
44 beyond EMG analysis of limited muscles. Participants who avoided high medial knee
45 displacement utilized greater proximal JRS.
Key Words: lumbar spine, hip, biomechanics, musculoskeletal modelling, dynamic valgus
46 Introduction
47 Neuromuscular deficits of the trunk and hip musculature may contribute to non-contact
48 anterior cruciate ligament (ACL) injury mechanisms such as dynamic knee valgus. However,
49 comprehensive examination and characterization of such deficits are incomplete in the literature.
50 Dynamic (knee) valgus is characterized by hip adduction and knee abduction when the knee has
51 collapsed medially and joint structures experience excessively high loads, though multi-planar
52 kinematics at the lower extremity joints can also contribute to dynamic valgus.21,50,57 Recent
53 evidence implicating aberrant trunk and hip kinematics in dynamic valgus behavior provides a
54 rationale for the mechanism being a proximal-to-distal process. 5,20,23,51
55 The likelihood of dynamic valgus inducing harmful ACL forces and strains have been
56 documented previously in the literature.18,25,33,36,59 Thus, evaluation of dynamic valgus as a

57 measure of ACL injury risk is well established.17,20–22,31,42,43,47,56 Given its utility in screening for
58 injury risk, the drop vertical jump (DVJ) is a common task employed in research and the clinic to
59 evaluate dynamic valgus.22,28,42,44,47,48 However, beyond kinematic and kinetic characterization,
60 and limited EMG analyses, insufficient work has been conducted to understand the mechanism
61 of dynamic valgus. This deficit motivated the current investigation of muscle activation patterns
62 and proximal joint stiffness.
2
63 A growing body of literature suggests that many traumatic knee injuries are due to
64 aberrant hip kinematics.50 In the sagittal plane a trade-off exists between the hips and knees upon
65 bilateral landing. In general, landing with an anterior lean of the trunk has been associated with
66 decreased knee-extensor moments and increased hip-extensor moments; conversely landing with
67 an erect trunk has been associated with the reverse.50,51 Additionally, anterior-posterior trunk
68 lean serves to modulate the strain and forces experienced by the ACL.4,29,50 In the frontal and
69 transverse planes, of particular importance is the role of hip adduction and internal rotation as
70 primary contributors to medial knee displacement (MKD) and creating a valgus posture.47,53,58
71 During hip adduction, the knee joint moves medially, allowing dynamic valgus and large knee
72 abduction moments to occur.20,58 Powers (2010)50 noted that females who relied predominantly
73 on the hip musculature to absorb impact forces during landing had reduced knee valgus angles,
74 abduction moments, and energy absorption at the knee. Several studies have noted weakness in
75 hip extension, external rotation, and abduction in those who display valgus during dynamic tasks,
76 or go on to suffer knee injuries.1,14,57 However, it has been demonstrated that dynamic valgus and
77 the associated mechanics can be reduced immediately following feedback and technique
78 coaching, indicating that landing biomechanics were independent of muscle strength. 19,31,41
79 Hip abduction and external rotation are predominantly achieved by gluteus medius and
80 gluteus maximus, respectively. 27,45,60 As such, these are muscles of interest when considering the
81 mechanism of dynamic valgus. To date, muscles of the gluteal complex have been evaluated
82 only for their activation amplitude, onset/offset timing, duration of activity and their link to
83 aberrant hip kinematics.1,57,63 While such analyses are insightful, they cannot provide direct
84 evidence regarding the mechanical contribution of the muscle’s ability to resist kinematics
85 contributing to dynamic valgus.
3
86 Considering the importance of controlling trunk and hip kinematics, it has been
87 postulated that neuromuscular factors are the primary mechanism of dynamic valgus. Prospective
88 studies have successfully predicted knee injury (inclusive of ligamentous and meniscus) and
89 ACL injury in females with high sensitivity (ranging between 84-91%) when considering
90 neuromuscular factors related to core stability in their predictive models.61,62 Furthermore,
91 purposeful core (trunk) muscular engagement has been shown to decrease frontal plane hip
92 displacement and increase knee flexion angle.55 Core stability has been defined as the ability to
93 dynamically control the trunk over the pelvis in order to allow optimal production, transfer and
94 control of forces and motion to distal segments of the kinetic chain.26,61 Thus, the dynamic
95 control of the knee is dependent on all contributing segments to the movement, starting
96 proximally with the trunk and radiating distally through the hips.
97 The role of trunk musculature to provide stiffness and stability to the spine is well
98 documented.3,7–9,12,49,52 The mechanical stability of a joint is dependent on the active, passive,
99 and control system’s ability to contribute stiffness to the joint. The control system includes the
100 CNS, which modulates joint stiffness via surrounding muscular contributions (active system).46
101 Muscle stiffness is the elastic energy stored upon deformation, and is dependent on activation,
102 force, and length.8,13,30 Joint rotational stiffness is the elastic resistance to rotational joint motion,
103 that is dependent on muscle stiffness and the geometric orientation (muscle attachment
104 coordinates, length, moment arm) of musculature about the joint.10–12 Muscle stiffness and its
105 contribution to joint rotational stiffness, is a function of neural drive in response to
106 proprioceptive feedback and the instantaneous task demand constraints.8,10,12,30,38 In the absence
107 of sufficient stiffness joint integrity is compromised, whereby instability and aberrant joint
108 micromovements can occur and/or structures may be unable to resist perturbations and excessive
4
109 motion.12,37 Joint rotational stiffness (JRS) analyses provide a unique method for which to
110 encapsulate the effect of musculature around a joint of interest, by incorporating the effect of
111 active muscle stiffness and their geometric orientation given segment kinematics. Quantification
112 of JRS facilitates analysis beyond muscle activation in isolation and provides insight into the
113 mechanical ability of musculature to resist rotational perturbations.
114 The evidence linking kinematic and neuromuscular involvement of the trunk and hip in
115 dynamic valgus, suggests that a biologically robust method of investigating proximal JRS in their
116 ability to prevent dynamic valgus is justifiable. Muscle activation patterns integration with safe
117 or aberrant kinematics have never been documented before for the musculature of the trunk
118 during a DVJ, yet such an analysis is critical in the formation of evidence-based prevention
119 strategies. Lumbar spine mechanics were of particular interest given the hypothesis that the
120 mechanism is a proximal-to-distal process, and that lumbar spine motion influences trunk
121 position, pelvic orientation, hip kinematics, and knee control. Given the frontal and transverse
122 plane hip kinematics that create dynamic valgus, of specific interest at the hip were the
123 contributions of gluteus medius and gluteus maximus to JRS in the frontal and transverse planes,
124 respectively. Therefore, the purpose of this work was to conduct a mechanistic investigation
125 aimed at elucidating and characterizing proximal neuromuscular mechanisms contributing to

126 dynamic valgus.
127 We hypothesized that greater lumbar spine flexion angles and reduced sagittal plane
128 lumbar spine JRS would be observed in participants who displayed bilateral valgus compared to
129 those who displayed no valgus on either limb. Additionally, we hypothesized that limbs
130 characterized as low valgus would display greater gluteus medius JRS in the frontal plane and
131 greater gluteus maximus JRS in the transverse plane, compared to high valgus limbs. This work
5
132 aims to provide insight into the motor control component of avoiding dynamic valgus, by linking
133 proximal JRS to the frontal plane control of the knee joint. Insight into the mechanisms
134 influencing valgus obtained here may assist in enhancing efforts to reduce future risk of non-
135 contact ACL injury. Insight from the results of this study may inform evidence-based
136 interventions aimed at reducing dynamic valgus, and ultimately, an individual’s risk of non-
137 contact ACL injury.
138 Methods
139 Eighteen female participants (age: 20.7±1.3 years, height: 1.64±0.05 m, mass: 65.2±11.0
140 kg) volunteered from a university population for this cross-sectional study. Participants self-
141 reported no current or significant previous injury to, and no chronic or recurrent pain of, the low
142 back or lower extremities. Female participants inclusive of varsity and recreational athletes from
143 a variety of sports (soccer, basketball, volleyball, rugby, martial arts) were appropriate since they
144 are a subset of the population at particularly high risk for ACL injury. Before testing, each
145 participant read and signed written informed consent forms approved by the university research
146 ethics board.
147 Data Collection

148 Drop Vertical Jump Task
149 The DVJ involves the participant dropping both feet off a box (31cm in height, 10cm
150 from the force plates) landing each foot on a force plate before performing a maximal vertical
151 jump (Figure 1). The DVJ was described and demonstrated by a research assistant, participants
152 were asked to land with each foot on a force plate simultaneously and jump as high as they could
153 before landing back on the force plates. A trial was considered successful when both feet hit the
154 force plates simultaneously and the participant reported performing a maximal vertical jump.
6
155 Additionally, raw EMG signals were checked in real time for quality and veracity. Any trials
156 with obvious non-physiological spikes due to mechanical collision or motion of hardware were
157 not considered successful. Three successful trials of every task were performed.
158 Kinematics and Kinetics
159 VICON NexusTM (Los Angeles, CA, USA) motion capture tracked the three-dimensional
160 coordinates of reflective markers, sampled at a rate of 60 Hz. Reflective markers adhered over
161 the following landmarks bilaterally allowed for segment definition: 1st and 5th metatarsal heads,
162 posterior and inferior base of calcaneus, medial and lateral malleoli, medial and lateral femoral
163 condyles, greater trochanters, iliac crests, acromia, sternum, and C7. Rigid body plates
164 containing a minimum of 4 reflective markers, to track segment movement during tasks, were
165 adhered over the following segments: feet, legs, thighs, sacrum, and T12. Ground reaction forces
166 and moments were recorded from two in-ground force plates (AMTI, Watertown, Mass, USA)
167 oriented adjacent to one another sampled at a rate of 2160 Hz.
168 Electromyography (EMG)
169 Twenty-four channels of EMG were collected bilaterally over the following muscles:
170 rectus abdominis, external oblique, internal oblique, latissimus dorsi, upper (thoracic) erector
171 spinae, lower (lumbar) erector spinae, tensor facsia latae, gluteus medius, gluteus maximus,
172 rectus femoris, biceps femoris, and adductor longus. Ag-AgCl surface electrode pairs were
173 positioned with an inter-electrode distance of approximately 2.5 cm and oriented in series,
174 parallel to the direction of the muscle fibers.
175 Each participant performed a maximal voluntary isometric contraction (MVC) of each
176 muscle for normalization. The EMG signals were amplified and analog-to-digital converted with
7
177 a 16-bit converter at a sample rate of 2160 Hz using the VICON NexusTM (Los Angeles, CA,
178 USA) system software.
179 Reference Voluntary Contraction (RVC)
180 A reference voluntary contraction (RVC) was collected as a calibration procedure to tune
181 the EMG-driven musculoskeletal models to each participant. The RVC for the lumbar spine
182 involved the participant standing upright holding a 9.07 kg plate directly in front of their body in
183 both hands with full elbow extension and shoulders flexed to approximately 90o. For the hips a
184 similar RVC was used while the participants were in a semi-squat position.
185 Data Processing

186 Kinematics
187 Visual 3D software (C-Motion, Rockville, MD) was used to calculate functional joint
188 centers of the hip and knee.2,54 Three-dimensional joint kinematics were calculated in Visual 3D
189 using rigid body segment clusters for the lumbar spine (sacrum and T12), hips (pelvis and
190 femur), and knees (femur and shank) and known anatomical landmarks to form orthopedic
191 angles from Euler rotation sequences of the following order: (i) flexion/extension, (ii) lateral
192 bend of the spine, abduction/adduction of hip and knee, and (iii) axial rotation of the spine,
193 internal/external rotation of hip and knee. Kinematic data were low-pass second-order
194 Butterworth filtered (dual pass) to produce a final cut-off frequency of 6 Hz (effectively creating
195 a fourth-order zero lag filter).
196 A body-fixed hip-ankle plane was created using the hip joint center, ankle joint center,
197 and a virtual marker (anterior to the ankle joint center) in Visual 3D to calculate frontal plane
198 knee displacement throughout the duration of the task. Frontal plane knee displacement was
8
199 calculated as the perpendicular distance between the functional knee joint center and the hip-
200 ankle plane. MKD represents a valgus posture of the lower extremity. The peak MKD of all trials
201 of the DVJ task were recorded before calculating the median value. An exclusion range of ± 20%
202 around the median was defined and provided the thresholds to determine high or low
203 valgus status for the given limb, such that high valgus were those greater than the median + 20%.
204 Each limb's valgus status was independently defined, this split the groups into ‘High Valgus’ and
205 ‘Low Valgus’ for the analysis of gluteal contributions to hip JRS. For the analysis of lumbar
206 spine variables, the participants were split into three groups: ‘Bilateral Valgus’ in which both
207 limbs were classified as high valgus, ‘Unilateral Valgus’ when either limb was high valgus, or
208 ‘No Valgus’ when both limbs were low valgus.

209 Electromyography
210 EMG data were digitally bandpass filtered between 30 and 500 Hz using second-order
211 zero phase lag (dual pass) Butterworth filters.15 Steps in digitally processing the raw EMG
212 included: removing the DC bias, full wave rectification, and linear envelope using a low-pass
213 Butterworth filter with a cut-off frequency of 2.5 Hz.6 The filtered LE signal were then
214 normalized to the maximum muscle activation elicited during the MVC for the given muscle.
215 EMG data were then down-sampled to be time synchronized with kinematic data sampled at 60
216 Hz.
217 EMG-driven modelling for the estimation of Joint Rotational Stiffness (JRS)
218 Details of the EMG-driven modelling processes (Figure 2) and methods to estimate JRS
219 at the lumbar spine and hips can be found in detail in the Supplementary Material. Briefly,
220 anatomically detailed EMG-driven biomechanical models of the lumbar spine and hips were
221 used (comprising 228 muscle fascicles in total) that are sensitive to individual movement and
9
222 motor control strategies. Lumbar spine JRS was calculated using a stability analysis that
223 evaluates the potential energy of the system.12,24,35,39 In order to calculate gluteus medius and
224 gluteus maximus contributions to hip JRS, equations developed by Potvin and Brown (2005)49
225 were used in conjunction with anatomical data of the Twente Lower Limb Model.27
226
227 Statistical Analysis
228 Peak variables of interest were averaged from three successful trials of a participant.
229 Lumbar spine flexion and lumbar spine sagittal JRS were primary variables of interest for
230 comparison between the three groups defined by both limbs valgus status (Bilateral Valgus,
231 Unilateral Valgus, No Valgus). A one-way ANOVA was conducted to compare the groups.
232 Additionally, the summation of each limb’s peak MKD allowed for a continuous variable to be
233 used in simple linear regression with each lumbar spine measure. Hip variables of interest were
234 peak gluteus medius frontal JRS and gluteus maximus transverse hip JRS. Since hip kinematics
235 are inherently considered within the JRS analysis and directly contribute to the frontal plane
236 displacement of the knee, they are not included in our statistical analyses as separate variables.
237 Each limb's valgus status was independently defined; therefore, groups of high and low valgus
238 were composed of the limbs defined as such. Comparison between high and low valgus groups
239 for gluteal JRS variables were done using t-tests, correcting for multiple comparisons using the
240 Bonferroni method. To test the association between gluteal JRS measures and MKD, multiple
241 linear regression was performed. Statistical significance was set at the p< 0.05 level for all tests.
242 All statistical analyses were performed in R.
10
243 Results
244 The mean peak MKD was 1.7 ± 0.8cm, the median value was 1.8cm while the thresholds
245 for determining high and low valgus were 2.1cm and 1.4cm, respectively. The mean, standard
246 deviation, and 90% confidence intervals are presented for lumbar variables (Table 1) and gluteal
247 JRS variables (Table 2). P-values and Hedges’ g effect sizes (ES) are presented in the tables for
248 group comparisons.
249 The no valgus group displayed a peak lumbar spine flexion angle of 24 ± 4o compared to
250 the bilateral valgus group’s angle of 38 ± 10o (p=0.09, ES=1.8) (Table 1). The peak lumbar spine
251 sagittal JRS between no valgus (1099 ± 114 Nm/rad) and bilateral valgus groups (646 ± 52
252 Nm/rad) had a very large effect size (ES=5.1, p=0.05) (Table 1). Simple linear regression for
253 lumbar spine flexion (Figure 3A) and sagittal JRS (Figure 3B) show little variance is accounted
254 for when using data from all valgus groups (7% and 23%), but a moderate amount of the
255 variance is explained when considering the data of only the bilateral and no valgus groups (56%
256 and 61%). Average time-series data of lumbar variables during the contact phase of the DVJ are
257 displayed in Figure 4 for each group.
258 Peak gluteus medius frontal JRS (p=0.002, ES=1.3) and gluteus maximus transverse JRS
259 (p=0.003, ES=1.2) were significantly greater in the low valgus compared to high valgus group
260 (Table 2). When entered into the multiple linear regression model (p=0.0003) gluteal JRS
261 contributions could account for 39% of the variance in MKD, indicating that a 1000 Nm/rad
262 increase in either of the gluteal JRS measures would result in a 1cm decrease in medial knee
263 displacement (Table 3). Figure 5 graphically displays the summation of peak gluteus medius and
264 gluteus maximus JRS in the frontal and transverse planes as a function of MKD.
11
265 Discussion
266 The primary results of this study indicate that those who avoided high MKD utilized
267 greater proximal JRS. Specifically, low valgus limbs generated greater gluteal JRS compared to
268 high valgus limbs. Remarkably, even with only 4 participants in each group, large effect sizes
269 indicate that participants displaying bilateral valgus also collapsed into lumbar spine flexion and
270 displayed substantially reduced lumbar spine sagittal JRS compared to the no valgus group. The
271 data collection and post-processing required to estimate JRS is extensive and limits the number
272 of cases that can be reasonably examined. Looking at the extremes of behavior and response
273 enhances the biological significance since the purpose of this work was to explore why some
274 people display valgus, while others do not. This was not an investigation of the behavior of the
275 group about a mean, rather it was to observe the features of those who are at the extremes – that
276 is where the signal of interest is. Stiffness is the variable the motor control system uses to control
277 motion throughout the linkage, and these results suggests a key role for proximal stiffness in
278 preventing dynamic valgus.
279 We hypothesized that greater lumbar spine flexion angles and reduced sagittal plane
280 lumbar spine JRS would be observed in participants who displayed bilateral valgus compared to
281 those who displayed no valgus. Such small sample sizes do not allow for sufficient statistical
282 power, and as such conventional significance parameters were not likely to be reached. Despite
283 this limitation the groups were remarkably different in their peak lumbar spine flexion and
284 lumbar spine sagittal JRS (Table 1, Figure 4), as evidenced by very large effect sizes. Therefore,
285 it is suggested that these results hold biological significance of considerable weight, particularly
286 since this is the first study of its kind to comprehensively evaluate trunk musculature in its
287 relation to dynamic valgus during a DVJ. In regard to the hip, we hypothesized that limbs
12
288 classified as low valgus would display greater gluteus medius JRS in the frontal plane and
289 greater gluteus maximus JRS in the transverse plane, compared to high valgus. Large effect sizes
290 between groups were observed in addition to statistical significance, thus highlighting the
291 importance of gluteus medius and maximus mechanical contributions to the prevention of
292 dynamic valgus.
293 Landing tasks are complex in that they involve multi-joint control and segment
294 coordination, while necessarily meeting the mechanical demands imposed by impact forces at
295 both the individual joints and the kinetic chain as a whole.40 As such, a variety of muscle
296 activation patterns and coordination strategies may be utilized to achieve the goals of the task
297 and support moment demands at various joints and in multiple planes of motion. The finding that
298 gluteal JRS contributions were significantly different between high and low valgus limbs, while
299 explaining a moderate amount of variance (39%), indicate that they are factors contributing
300 substantially to the control of the lower extremity during landing - but not the only factors.
301 Importantly though, the statistical power of the regression analysis suffers due to a small number
302 of data points in our sample.
303 The mechanical function of the gluteus medius and maximus substantiates their role in
304 JRS production in those who avoided dynamic valgus, since their frontal and transverse plane
305 moment arms make them ideal stiffeners in combination with muscle activation. Since MKD is
306 primarily a frontal plane motion, it is unsurprising that the largest magnitude of difference
307 between high and low valgus were found in gluteus medius’ frontal JRS contribution. The
308 reported threshold values for MKD used in this work correspond reasonably well with values by
309 a prospective study that reported a 1.2cm increase in MKD increased one’s risk of ACL injury
310 by 40%.28 Considering their risk assessment and the results of this work (Table 3), a 1000
13
311 Nm/rad decrease in either of the gluteal JRS measures would increase one’s risk of ACL injury
312 by 33%.
313 Hip flexion magnitudes between bilateral and no valgus groups differed less than 5o. This
314 suggests that the no valgus group avoided landing erect but did not collapse at the lumbar spine,
315 thus achieving an anterior trunk lean using a hip strategy to appropriately control the COM. This
316 highlights the need to quantify and understand how the anterior trunk lean is achieved (via
317 contributions from lumbar spine and/or hip flexion) and the differences in mechanics that
318 accompany such strategies during dynamic tasks.
319 Several works have linked a “stiffening strategy” (less trunk, hip, and knee flexion upon
landing) to increased ACL injury risk, given the increased loading at the knee joint. 4,31,32,50 A
320
321 few studies have evaluated ‘stiffness’ in varying forms including an average leg stiffness (peak
322 vGRF/body COM displacement) 34 and hip joint stiffness (moment/angle)16 that have conflicting
323 conclusions regarding differences in ‘stiffness’ between males and females and the relation to
324 ACL injury risk. However, such methods of calculating stiffness did not utilize measures of the
325 direct contribution of active musculature – this is the strength of our investigation. No previous
326 works, that the authors are aware of, have investigated JRS at the lumbar spine or hip
327 musculature as it relates to the mechanism of dynamic valgus or ACL injury. Nor have any
328 works investigated the role of the trunk and hip musculature to the extent of this work.
329 The major limitation of this work is the small sample size rendering statistical models
330 lacking in sufficient power for some variables. Eighteen university aged female recreational or
331 university level athletes comprised the sample. The use of thresholds to define valgus groups
332 further reduced the sample size for group comparisons and only provided relatively high or low
333 valgus based on the sample population, while it also included both limbs from some participants
14
334 and only single limbs from others. Given the cross-sectional study design, small sample size, and
335 large variability in variables of interest, inferences for the risk of injury as it relates to reduced
336 proximal JRS while promising, require further investigation. Inherent assumptions and
337 limitations exist in the use of generic EMG-driven biomechanical models. However, tuning of
338 the model with a participant specific gain factor, and the between group comparison rendering
339 any error systematic in nature, attempts to address these limitations. This mechanistic study was
340 designed to understand potential contributing factors to, and mechanisms of, dynamic valgus.
341 For participants in which a limb had conflicting valgus classification across trials, the kinematic
342 and JRS variables of each trial often varied in magnitude; averaging these trials occasionally
343 resulted in washing out differences between trials. Important mechanistic information might exist
344 in this variability that may be insightful for inferring injury risk.
345
346 Conclusion
347 This is the first work of its kind to specifically characterize lumbar spine and hip
348 neuromuscular mechanisms that may be responsible for dynamic valgus in the DVJ task, beyond
349 EMG analysis of limited muscles. Increased JRS at the lumbar spine and greater JRS
350 contributions from the gluteal musculature are linked with preventing high MKD. Increased
351 stiffness is not always prophylactic, as extremely high magnitudes may act to impose rigidity
352 within a system and prevent motion that may be necessary to dissipate forces and transfer energy
353 in a manner that reduces injury risk. However, in this work increased stiffness was deemed to be
354 appropriate and sufficient, as it was regularly a pre-condition to prevent high MKD. Stiffness is a
355 variable that is tuned by the motor control system with tradeoffs between motion, stress
356 distribution and migration, injury resilience, and performance. This advance provides a
15
357 springboard for future work that should aim to develop training interventions for increasing an
358 individual’s proximal JRS to avoid dynamic valgus during controlled and uncontrolled tasks.
359 Key Points
360 Findings: The data suggests that neuromuscular factors at the trunk and hip may be responsible
361 for dynamic valgus occurrence during a landing task. Specifically, an inability to generate
362 sufficient proximal JRS allows for high medial knee displacement.
363 Implications: This work suggests that prevention programs aimed at addressing neuromuscular
364 mechanisms related to non-contact ACL injury must do so with consideration of trunk and
365 gluteal musculature, and their coordinated activity to appropriately control the linkage.
366 Furthermore, the JRS approach facilitates analysis beyond muscle activation in isolation, and in
367 doing so advances understanding of the links inherent to cause and effect.
368 Caution: The JRS described in this work is not equivalent to ‘clinical stiffness’. When muscles
369 contract they create both force and stiffness that work together to control posture and dynamic
370 movement. Additionally, one must train sufficient stiffness in individuals with appropriate and
371 coordinated muscle activation patterns in combination with suitable movement patterns. The
372 optimal value of stiffness that is both appropriate and sufficient is unknown.
16
References
1. Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral
pain syndrome: a systematic review. Br J Sports Med. 2013;47:207-214.
doi:10.1136/bjsports-2012-090953.
2. Begon M, Monnet T, Lacouture P. Effects of movement for estimating the hip joint centre.
Gait Posture. 2007;25(3):353-359. doi:10.1016/j.gaitpost.2006.04.010.
3. Bergmark A. A study in mechanical engineering. Acta Orthop Scand Suppl.
1989;60(230):1-54.
4. Blackburn JT, Padua D a. Sagittal-plane trunk position, landing forces, and quadriceps
electromyographic activity. J Athl Train. 2009;44(2):174-179. doi:10.4085/1062-6050-
44.2.174.
5. Boden BP, Torg JS, Knowles SB, Hewett TE. Video analysis of anterior cruciate ligament
injury: abnormalities in hip and ankle kinematics. Am J Sports Med. 2009;37(2):252-259.
doi:10.1177/0363546508328107.
6. Brereton LC, McGill SM. Frequency response of spine extensors during rapid isometric
contractions: effects of muscle length and tension. J Electromyogr Kinesiol.
1998;8(4):227-232. doi:10.1016/S1050-6411(98)00009-1.
7. Brown SH, Howarth SJ, McGill SM, Marshall PW, Murphy B a. Spine stability and the
role of many muscles. Arch Phys Med Rehabil. 2005;86:1890-1891.
doi:10.1016/j.apmr.2005.07.281.
8. Brown SHM, McGill SM. Muscle force-stiffness characteristics influence joint stability: a
17
spine example. Clin Biomech. 2005;20(9):917-922.
doi:10.1016/j.clinbiomech.2005.06.002.
9. Brown SHM, McGill SM. The intrinsic stiffness of the in vivo lumbar spine in response to
quick releases: implications for reflexive requirements. J Electromyogr Kinesiol.
2009;19(5):727-736. doi:10.1016/j.jelekin.2008.04.009.
10. Brown SHM, Potvin JR. Exploring the geometric and mechanical characteristics of the
spine musculature to provide rotational stiffness to two spine joints in the neutral posture.
Hum Mov Sci. 2007;26:113-123. doi:10.1016/j.humov.2006.09.006.
11. Cashaback JG a, Potvin JR. Knee muscle contributions to joint rotational stiffness. Hum
Mov Sci. 2012;31(1):118-128. doi:10.1016/j.humov.2010.12.005.
12. Cholewicki J, McGill SM. Mechanical stability of the in vivo lumbar spine: implications
for injury and chronic low back pain. Clin Biomech. 1996;11(1):1-15.
13. Cholewicki J, McGill SM. Relationship between muscle force and stiffness in the whole
mammalian muscle: a simulation study. J Biomech Eng. 1995;117:339-342.
14. Collado H, Fredericson M. Patellofemoral pain syndrome. Clin Sports Med. 2010;29:379-
398. doi:10.1016/j.csm.2010.03.012.
15. Drake JDM, Callaghan JP. Elimination of electrocardiogram contamination from
electromyogram signals: An evaluation of currently used removal techniques. J
Electromyogr Kinesiol. 2006;16(2):175-187. doi:10.1016/j.jelekin.2005.07.003.
16. Ford KR, Myer GD, Hewett TE. Longitudinal effects of maturation on lower extremity
joint stiffness in adolescent athletes. Am J Sports Med. 2010;38(9):1829-1837.
18
doi:10.1177/0363546510367425.
17. Ford KR, Myer GD, Smith RL, Vianello RM, Seiwert SL, Hewett TE. A comparison of
dynamic coronal plane excursion between matched male and female athletes when
performing single leg landings. Clin Biomech. 2006;21(1):33-40.
18. Fukuda Y, Woo SLY, Loh JC, et al. A quantitative analysis of valgus torque on the ACL:
A human cadaveric study. J Orthop Res. 2003;21(6):1107-1112. doi:10.1016/S0736-
0266(03)00084-6.
19. Herman DC, Oñate J a, Weinhold PS, et al. The effects of feedback with and without
strength training on lower extremity biomechanics. Am J Sports Med. 2009;37(7):1301-
1308. doi:10.1177/0363546509332253.
20. Hewett TE, Myer GD. The Mechanistic Connection Between the Trunk, Hip, Knee, and
Anterior Cruciate Ligament Injury. Exerc Sport Sci Rev. 2011;39(4):161-166.
21. Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes:
Part 1, mechanisms and risk factors. Am J Sports Med. 2006;34(2):299-311.

doi:10.1177/0363546505284183.
22. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control
and valgus loading of the knee predict anterior cruciate ligament injury risk in female
athletes: a prospective study. Am J Sports Med. 2005;33:492-501.
doi:10.1177/0363546504269591.
23. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-
19
contact anterior cruciate ligament injury in female athletes: lateral trunk and knee
abduction motion are combined components of the injury mechanism. Br J Sports Med.
2009;43:417-422. doi:10.1136/bjsm.2009.059162.
24. Howarth SJ. MSc Thesis. 2006.
25. Kanamori A, Woo SLY, Ma CB, et al. The forces in the anterior cruciate ligament and
knee kinematics during a simulated pivot shift test: A human cadaveric study using
robotic technology. Arthroscopy. 2000;16(6):633-639. doi:10.1053/jars.2000.7682.
26. Kibler W Ben, Press J, Sciascia A. The role of core stability in athletic function. Sport
Med. 2006;36(3):189-198. doi:10.2165/00007256-200636030-00001.

27. Klein Horsman MD, Koopman HFJM, van der Helm FCT, Prosé LP, Veeger HEJ.
Morphological muscle and joint parameters for musculoskeletal modelling of the lower
extremity. Clin Biomech. 2007;22:239-247. doi:10.1016/j.clinbiomech.2006.10.003.
28. Krosshaug T, Steffen K, Kristianslund E, et al. The Vertical Drop Jump Is a Poor
Screening Test for ACL Injuries in Female Elite Soccer and Handball Players: A
Prospective Cohort Study of 710 Athletes. Am J Sports Med. 2016;44(4):874-883.

doi:10.1177/0363546515625048.
29. Kulas AS, Hortobágyi T, Devita P. Trunk position modulates anterior cruciate ligament
forces and strains during a single-leg squat. Clin Biomech. 2012;27(1):16-21.
30. Latash ML, Zatsiorsky VM. Joint stiffness: Myth or reality? Hum Mov Sci. 1993;12:653-
692. doi:10.1016/0167-9457(93)90010-M.
20
31. Laughlin WA, Weinhandl JT, Kernozek TW, Cobb SC, Keenan KG, O’connor KM. The
effects of single-leg landing technique on ACL loading. J Biomech. 2011;44(10):1845-
1851. doi:10.1016/j.jbiomech.2011.04.010.
32. Leppänen M, Pasanen K, Kujala UM, et al. Stiff Landings Are Associated With Increased
ACL Injury Risk in Young Female Basketball and Floorball Players. Am J Sports Med.
2016;45(2):386-393. doi:10.1177/0363546516665810.
33. Lloyd DG, Buchanan TS. Strategies of the muscular contributions to the support of static
varus and valgus loads at the human knee. J Biomech. 2001;34:1257-1267.
34. Lyle M a., Valero-Cuevas FJ, Gregor RJ, Powers CM. Control of dynamic foot-ground
interactions in male and female soccer athletes: Females exhibit reduced dexterity and
higher limb stiffness during landing. J Biomech. 2014;47(2):512-517.
doi:10.1016/j.jbiomech.2013.10.038.
35. Ma S, Zahalak GI. A distribution-moment model of energetics in skeletal muscle. J
Biomech. 1991;24(1):21-35. doi:10.1016/0021-9290(91)90323-F.
36. Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finerman GAM, Slauterbeck JL.
Combined knee loading states that generate high anterior cruciate ligament forces. J
Orthop Res. 1995;13(6):930-935. doi:10.1002/jor.1100130618.
37. McGill SM. Linking latest knowledge of injury mechanisms and spine function to the
prevention of low back disorders. J Electromyogr Kinesiol. 2004;14(1):43-47.
doi:10.1016/j.jelekin.2003.09.012.
38. McGill SM. Low Back Disorders: Evidence Based Prevention and Rehabilitation. Second.
21
Chicago, IL: Human Kinetics; 2007.
39. McGill SM, Norman RW. Partitioning of the L4-L5 Dynamic Moment into Disc,
Ligamentous, and Muscular Components During Lifting. Spine (Phila Pa 1976).
1986;11(7):666-678.
40. McNitt-Gray JL, Hester DME, Mathiyakom W, Munkasy BA. Mechanical demand and
multijoint control during landing depend on orientation of the body segments relative to
the reaction force. J Biomech. 2001;34(11):1471-1482. doi:10.1016/S0021-
9290(01)00110-5.
41. Mizner RL, Kawaguchi JK, Chmielewski TL. Muscle strength in the lower extremity does
not predict postinstruction improvements in the landing patterns of female athletes. J
Orthop Sports Phys Ther. 2008;38(6):353-361. doi:10.2519/jospt.2008.2726.
42. Myer GD, Ford KR, Hewett TE. New method to identify athletes at high risk of ACL
injury using clinic-based measurements and freeware computer analysis. Br J Sports Med.
2011;45(4):238-244. doi:10.1136/bjsm.2010.072843.
43. Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Clinical correlates to laboratory
measures for use in non-contact anterior cruciate ligament injury risk prediction algorithm.
Clin Biomech (Bristol, Avon). 2010;25(7):693-699.
44. Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Development and validation of a
clinic-based prediction tool to identify female athletes at high risk for anterior cruciate
ligament injury. Am J Sports Med. 2010;38(10):2025-2033.
doi:10.1177/0363546510370933.
22
45. Neumann DA. Kinesiology of the hip: A focus on muscular actions. Jounral Orthop Sport
Phys Ther. 2010;40(2):82-94. doi:10.2519/jospt.2010.3025.
46. Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction,
adaptation, and enhancement. J Spinal Disord. 1992;5:383-389.
47. Pollard CD, Sigward SM, Ota S, Langford K, Powers CM. The influence of in-season
injury prevention training on lower-extremity kinematics during landing in female soccer
players. Clin J Sport Med. 2006;16(3):223-227. doi:10.1097/00042752-200605000-00006.
48. Pollard CD, Sigward SM, Powers CM. Limited hip and knee flexion during landing is
associated with increased frontal plane knee motion and moments. Clin Biomech.
2010;25(2):142-146. doi:10.1016/j.clinbiomech.2009.10.005.
49. Potvin JR, Brown SHM. An equation to calculate individual muscle contributions to joint
stability. J Biomech. 2005;38(5):973-980. doi:10.1016/j.jbiomech.2004.06.004.
50. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical
perspective. J Orthop Sports Phys Ther. 2010;40(2):42-51. doi:10.2519/jospt.2010.3337.
51. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint
dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639-646.
doi:10.2519/jospt.2003.33.11.639.
52. Reeves NP, Narendra KS, Cholewicki J. Spine stability: Lessons from balancing a stick.
Clin Biomech. 2011;26:325-330. doi:10.1016/j.clinbiomech.2010.11.010.
53. Reiman MP, Bolgla L a, Lorenz D. Hip functions influence on knee dysfunction: a
proximal link to a distal problem. J Sport Rehabil. 2009;18(1):33-46.
23
54. Schwartz MH, Rozumalski A. A new method for estimating joint parameters from motion
data. J Biomech. 2005;38(1):107-116. doi:10.1016/j.jbiomech.2004.03.009.
55. Shirey M, Hurlbutt M, Johansen N, King GW, Wilkinson SG, Hoover DL. The influence
of core musculature engagement on hip and knee kinematics in women during a single leg
squat. Int J Sports Phys Ther. 2012;7(1):1-12.
56. Sigward SM, Ota S, Powers CM. Predictors of frontal plane knee excursion during a drop
land in young female soccer players. J Orthop Sports Phys Ther. 2008;38(11):661-667.
doi:10.2519/jospt.2008.2695.
57. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle
activation between subjects with and without patellofemoral pain. J Orthop Sports Phys
Ther. 2009;39(1):12-19. doi:10.2519/jospt.2009.2885.
58. Souza RB, Powers CM. Predictors of hip internal rotation during running: an evaluation of
hip strength and femoral structure in women with and without patellofemoral pain. Am J
Sports Med. 2009;37:579-587. doi:10.1177/0363546508326711.
59. Utturkar GM, Irribarra L a., Taylor K a., et al. The effects of a valgus collapse knee
position on in vivo ACL elongation. Ann Biomed Eng. 2013;41(1):123-130.
doi:10.1007/s10439-012-0629-x.
60. Ward SR, Winters TM, Blemker SS. The Architectural Design of the Gluteal Muscle
Group: Implications for Movement and Rehabilitation. J Orthop Sport Phys Ther.
2010;40(2):95-102. doi:10.2519/jospt.2010.3302.
61. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in
24
neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-
epidemiologic study. Am J Sports Med. 2007;35(7):1123-1130.
doi:10.1177/0363546507301585.
62. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. The effects of core
proprioception on knee injury: a prospective biomechanical-epidemiological study. Am J
Sports Med. 2007;35(3):368-373. doi:10.1177/0363546506297909.
63. Zazulak BT, Ponce PL, Straub SJ, Medvecky MJ, Avedisian L, Hewett TE. Gender
comparison of hip muscle activity during single-leg landing. J Orthop Sports Phys Ther.
2005;35(5):292-299. doi:10.2519/jospt.2005.1734.
25
Figures
Figure 1: The stages of a standard DVJ from a 31 cm box onto two adjacent force plates. The
participant begins feet shoulder width apart with the toes at the edge of the box (A). The
participant initiates movement by ‘dropping’ 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).

Anthropometric External Force
Kinematic Data EMG
Data (Force Plate Data)
Link Segment
Model
3D Reaction 3D Joint
Force and Angles
Moment
Muscle Model
Individual Muscle (Lumbar: DM)
Joint Model Length, Velocity, (Hip: Hill-Type)
PCSA
Individual Muscle
Generalized
Individual Muscle
Coordinates
Force and
Least Squares Stiffness
Difference
Joint Forces and

Moments
Common Gain
Joint Rotational
Stiffness Analysis
Figure 2: An overview of the EMG-driven modelling processes used for the lumbar spine and
hip are presented to demonstrate the inputs, processing, and outputs of each subcomponent as
well as the interactions between them to comprise the complete model.

Summed Medial Knee Displacement (cm)
Downloaded from www.jospt.org by La
2
R = 0.23
2
R = 0.56
A
- - = All Groups
Summed Medial Knee Displacement (cm)

= Bilateral & No Valgus Groups
B
2
R = 0.61
2
R = 0.07
Figure 3: Scatter plots of A) lumbar spine flexion angle and B) lumbar spine sagittal Joint
Rotational Stiffness (JRS) versus summed medial knee displacement during the drop vertical
jump task. Grey dashed lines are the regression fit considering all groups’ data, black solid lines
are the regression fit on only the bilateral and no valgus data. Note the clustering of no valgus
and bilateral valgus groups at either end of the spectrum. High summed medial knee
displacement values in the unilateral valgus group may be driven primarily from one limb.
Bilateral Valgus Unilateral Valgus No Valgus
40
Angle (deg)
30
20 A
10
1000
JRS (Nm/rad)
750
B
500
250
0 25 50 75 100 0 25 50 75 100 0 25 50 75 100
Time (normalized)
Figure 4: Average time-series data of lumbar spine flexion angle (A); and sagittal plane lumbar
spine Joint Rotational Stiffness (JRS) (B) during the stance phase of the drop vertical jump task
for each group.

J Orthop Sports Phy
Downloaded from w
Figure 5: Scatter plot displays gluteal musculature’s combined contribution to hip Joint
Rotational Stiffness (JRS) in the frontal and transverse planes versus peak medial knee
displacement during the drop vertical jump task.

Table 1: Comparison of peak lumbar spine flexion and sagittal joint rotational stiffness (JRS) between valgus
groups (BV: Bilateral Valgus, UV: Unilateral Valgus, NV: No Valgus). Mean ± Standard Deviation and 90%
confidence intervals are presented for each group. (ES = Hedges’ g effect size)
BV UV NV BV-UV BV-NV UV-NV

(n = 4) (n = 10) (n = 4)
Lumbar
Spine 38 26 24 ES = 1.4 ES = 1.8 ES = 0.3
Flexion ± 10 ±8 ±4
Angle (o) (29, 46) (9, 44) (5, 43) ANOVA: p = 0.09
Lumbar
Spine 646 833 1099 ES = 0.8 ES = 5.1 ES = 1.1
Sagittal JRS ± 52 ± 278 ± 114
(Nm/rad) (418, 873) (339, 1327) (571, 1627) ANOVA: p = 0.05
Table 2: Comparison of peak gluteus medius frontal plane joint rotational stiffness (JRS) and gluteus maximus
transverse plane JRS between high and low valgus groups. Mean ± Standard Deviation and 90% confidence
intervals are presented for each group. (ES = Hedges’ g effect size)
High Valgus Low Valgus High Valgus – Low Valgus

(n = 11) (n = 13)
Gluteus Medius 1076 2708 p = 0.002 *

Frontal ± 708 ± 1505 ES = 1.3
JRS (Nm/rad) (550, 1603) (1450, 3965)
Gluteus Maximus 290 698 p = 0.003 *

Transverse JRS ± 194 ± 431 ES = 1.2
(Nm/rad) (145, 434) (353, 1043)
* = Indicates statistically significant p-value after correcting for multiple comparisons.

Table 3: Results of the multiple linear regression model using the gluteal musculature JRS
variables as predictors of medial knee displacement, indicate a significant model (p<0.01) as
denoted by the F Statistic. The coefficients indicate that a 1000 Nm/rad increase in either gluteal
JRS measure would result in a 1cm decrease in medial knee displacement.
Response variable:
Medial Knee Displacement
G.Med Frontal JRS -0.001*
(0.0004)
G. Max Transverse JRS -0.001
(0.001)
Constant 2.537***
(0.257)
Observations 36
R2 0.392
Adjusted R2 0.355
Residual Std. Error 0.863 (df = 33)
F Statistic 10.641*** (df = 2; 33)
*
Note: p<0.1; **p<0.05; ***p<0.01
ACL Injury Mechanisms and the Kinetic Chain Linkage Cannon et al 2019
Supplementary Material
Methods
Lumbar Spine Model
Lumbar spine joint rotational stiffness (JRS) was quantified using a three-dimensional
anatomically detailed lumbar spine model (Figure 2 of manuscript) (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 to the model. A distribution-moment model (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 torsional springs (Figure A.1). The resulting 18 degree-
of-freedom (DoF) lumbar spine model produces an 18x18 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 summation of the
contributions from the muscle fascicles (linear springs), passive tissues (torsional springs), and
that from any externally applied loads. Each diagonal element of the Hessian matrix represents
the joint rotational stiffness about a particular axis of a joint in the lumbar spine, of interest in
this work were the three axes about L4/L5 since 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.
Figure A.1: An overview of the Stability Analysis run following the Lumbar Spine Model. Note: for this work the
values of interest were the JRS 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 joint rotational stiffness (JRS), equations developed by Potvin
and Brown (2005)12 were used in conjunction with anatomical data reported by Klein Horsman
et al. (2007)8. An overview of the modelling processes that provide the variables necessary for
the hip JRS analysis can be seen in Figure 2 of manuscript. 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.
𝐴𝑌 𝐵𝑌 + 𝐴𝑍 𝐵𝑍 − 𝑟𝑥2 𝑞𝑟𝑥2
𝐽𝑅𝑆𝑥 = 𝐹𝑚 [ + ] (1)
𝑙 𝐿
Where,
𝐽𝑅𝑆𝑥 = the rotational stiffness contribution of a muscle about the x-axis of the hip joint
𝐹 = force of a particular muscle ‘m’
𝑙 = 3D length of the muscle vector that crosses the hip joint
𝐿 = full 3D length of the muscle
𝑟 = 3D muscle moment arm
𝐴𝑋 , 𝐴𝑌 , 𝐴𝑍 = origin coordinates with respect to hip joint center at (0,0,0)

𝐵𝑋 , 𝐵𝑌 , 𝐵𝑍 = insertion (or initial node) coordinates with respect to hip joint center at (0,0,0)
𝑞 = muscle stiffness coefficient relating muscle force and length
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 Limb Model’.8 Muscles were split into anatomically
and functionally relevant muscle parts, where a number of elements are used to model the muscle
geometry most accurately.
2) Muscle Force
Instantaneous muscle force were calculated using a Hill-type muscle model. Normalized
EMG corrected for length, velocity, and passive tissue contributions were calculated (Equation
2).11 Muscle characteristics (PCSA, Lo, pennation angle) required in the hip muscle force
calculations were taken from the Twente Lower Limb Model.8
EMG
Fm = G [(EMG ) (𝑃𝐶𝑆A)(𝜎𝑚𝑎𝑥 )(Ω)(δ) + FPEC ] (2)
max
Where,
Fm = Muscle force (N)

G = Participant specific gain
𝐸𝑀𝐺
= Normalised EMG amplitude
𝐸𝑀𝐺𝑚𝑎𝑥
PCSA = Physiological Cross-Sectional Area

𝜎𝑚𝑎𝑥 = Maximum muscle stress
𝛺 = Coefficient for force-velocity correction
δ = Coefficient for force-length correction
FPEC = Force due to the passive elastic component
Differences in hip musculature’s mechanistic capability were preserved, however some
deep muscle activation were 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 (1989)
𝑞𝐹 (3)
𝑘=
𝐿
Where,
𝑘 = muscle stiffness
𝐹 = muscle force
𝐿 = total muscle length from origin to insertion
𝑞 = muscle stiffness coefficient relating muscle force and length
Reference Voluntary Contraction (RVC)
A reference voluntary contraction (RVC) 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 of manuscript) 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
∑𝐹𝑟𝑎𝑚𝑒𝑠
𝑓=1 (𝑀𝐿𝑆𝑀 − 𝐺 · 𝑀𝐸𝑀𝐺 )2 = 𝑚𝑖𝑛 (4)
References
1. Bergmark A. A study in mechanical engineering. Acta Orthop Scand Suppl.
1989;60(230):1-54.
2. Brown SHM, 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(5):743-751. doi:10.1080/00140130701194926.
3. Cashaback JG a, Potvin JR. Knee muscle contributions to joint rotational stiffness. Hum
Mov Sci. 2012;31(1):118-128. doi: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. 1996;11(1):1-15.
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(3):321-331.
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(5):1155-1163.
doi:10.1016/j.jbiomech.2004.05.022.
7. Howarth, S. J. (2006). Locating Instability in the Lumbar Spine: Characterizing the
eigenvector. MSc Thesis, University of Waterloo.
8. Klein Horsman MD, Koopman HFJM, van der Helm FCT, Prosé LP, Veeger HEJ.
Morphological muscle and joint parameters for musculoskeletal modelling of the lower
extremity. Clin Biomech. 2007;22:239-247. doi:10.1016/j.clinbiomech.2006.10.003.

9. Ma S, Zahalak GI. A distribution-moment model of energetics in skeletal muscle. J
Biomech. 1991;24(1):21-35. doi:10.1016/0021-9290(91)90323-F.
10. McGill SM, Juker D, Kropf P. Technical Note: Appropriately Placed Surface EMG
Electrodes Reflect Deep Muscle Activity (Psoas, Quadratus Lumborum, Abdominal Wall)
in the Lumbar Spine. J Biomech. 1996;29(11):1503-1507.
11. McGill SM, Norman RW. Partitioning of the L4-L5 Dynamic Moment into Disc,
Ligamentous, and Muscular Components During Lifting. Spine (Phila Pa 1976).
1986;11(7):666-678.
12. Potvin JR, Brown SHM. An equation to calculate individual muscle contributions to joint
stability. J Biomech. 2005;38(5):973-980. doi:10.1016/j.jbiomech.2004.06.004.


ACL Injury Mechanisms and The Kinetic Chain Linkage: The Effect of Proximal Joint Stiffness On Distal Knee Control During Bilateral Landings

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ACL Injury Mechanisms and The Kinetic Chain Linkage: The Effect of Proximal Joint Stiffness On Distal Knee Control During Bilateral Landings

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ACL Injury Mechanisms and the Kinetic Chain Linkage: The Effect of Proximal Joint

Stiffness on Distal Knee Control during Bilateral Landings

* Current: Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and

✝ Worked performed at: Spine Biomechanics Laboratory, Department of Kinesiology,

Support: Natural Sciences and Engineering Research Council of Canada

Review Board: University of Waterloo Office of Research Ethics

Division of Biokinesiology and Physical Therapy,

23 Stiffness on Distal Knee Control During Bilateral Landings

25 Study Design: Cross-sectional

27 gluteal musculature contribution to hip JRS, on dynamic knee valgus.

29 valgus and ACL injury mechanisms. However, comprehensive examination of neuromuscular

30 patterns and their mechanical influence are lacking.

34 displacement magnitude. We used anatomically-detailed EMG-driven biomechanical models to

35 quantify lumbar spine JRS and muscle contributions to hip JRS.

41 bilateral high valgus group’s angle of 38 ± 10o (p=0.09, ES=1.8).

45 displacement utilized greater proximal JRS.

54 rationale for the mechanism being a proximal-to-distal process. 5,20,23,51

56 documented previously in the literature.18,25,33,36,59 Thus, evaluation of dynamic valgus as a

59 evaluate dynamic valgus.22,28,42,44,47,48 However, beyond kinematic and kinetic characterization,

62 and proximal joint stiffness.

85 contributing to dynamic valgus.

90 neuromuscular factors related to core stability in their predictive models.61,62 Furthermore,

98 documented.3,7–9,12,49,52 The mechanical stability of a joint is dependent on the active, passive,

105 contribution to joint rotational stiffness, is a function of neural drive in response to

113 mechanical ability of musculature to resist rotational perturbations.

125 aimed at elucidating and characterizing proximal neuromuscular mechanisms contributing to

126 dynamic valgus.

137 contact ACL injury.

146 ethics board.

147 Data Collection

148 Drop Vertical Jump Task

158 Kinematics and Kinetics

167 oriented adjacent to one another sampled at a rate of 2160 Hz.

168 Electromyography (EMG)

174 parallel to the direction of the muscle fibers.

178 USA) system software.

179 Reference Voluntary Contraction (RVC)

185 Data Processing

195 a fourth-order zero lag filter).

208 ‘No Valgus’ when both limbs were low valgus.

227 Statistical Analysis

242 All statistical analyses were performed in R.

248 group comparisons.

257 displayed in Figure 4 for each group.

278 preventing dynamic valgus.

292 dynamic valgus.

302 of data points in our sample.

318 accompany such strategies during dynamic tasks.

359 Key Points

pain syndrome: a systematic review. Br J Sports Med. 2013;47:207-214.

Gait Posture. 2007;25(3):353-359. doi:10.1016/j.gaitpost.2006.04.010.

3. Bergmark A. A study in mechanical engineering. Acta Orthop Scand Suppl.

electromyographic activity. J Athl Train. 2009;44(2):174-179. doi:10.4085/1062-6050-

injury: abnormalities in hip and ankle kinematics. Am J Sports Med. 2009;37(2):252-259.

contractions: effects of muscle length and tension. J Electromyogr Kinesiol.

role of many muscles. Arch Phys Med Rehabil. 2005;86:1890-1891.

quick releases: implications for reflexive requirements. J Electromyogr Kinesiol.

Hum Mov Sci. 2007;26:113-123. doi:10.1016/j.humov.2006.09.006.

Mov Sci. 2012;31(1):118-128. doi:10.1016/j.humov.2010.12.005.

mammalian muscle: a simulation study. J Biomech Eng. 1995;117:339-342.

15. Drake JDM, Callaghan JP. Elimination of electrocardiogram contamination from

electromyogram signals: An evaluation of currently used removal techniques. J