Journal of Orthopaedic & Sports Physical Therapy

1999;29(2):93-105

Effect of Foot Position on

Electromyographic Activity of the Vastus
Medialis Oblique and Vastus Lateralis
During Lower-Extremity

You-jou Hung, MS, PT1

Michael I Gross, PhD, PT2

Study Design: Repeated measures analysis of the effects of foot wedges on quadriceps

w iles et alS2sug-
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muscle function. gested that by

O b j e c t k To investigate the relationship between foot position and 2 quadriceps muscle age 30 over 90%
activation conditions: maximum voluntary isometric quadriceps muscle contractions with the of the general
knee extended and 1-leg short squats with a knee flexion range of motion of 0" to 50". population has
Background: Abnormal foot position has been suggested as an important factor which may some degree of pathologic
lead to patellofemoralmalalignment. No previous studies have examined the effects of foot changes of the patellofemoral
position on activation of the vastus medialis oblique (VMO) and vastus lateralis (VL) muscles joint. Also, approximately 30% of
using weight-bearing exercises. patients seen in a sports medicine
Methods and Measures: Sixteen healthy volunteers performed the 2 exercises under 3 foot clinic by Derscheid and Feiring7
conditions: level surface, a 10" medial wedge, and a 10" lateral wedge. Subjects' had patellofemoral joint com-
J Orthop Sports Phys Ther 1999.29:93-105.

electromyographic data for the VMO and VL were analyzed using ANOVA. plaints. Such reports suggest that
Resulb: The normalizedVMOIVL ratio was significantly greater during the short squat than patellofemoral pain syndrome is a
during the maximum voluntary isometric muscle contractions, but no significant differences very common disorder in sports
were identified across the 3 foot positions. medicine settings as well as in re-
Conclusions: Clinicians should understand that the benefit of using a foot orthotic to correct habilitation institutions. Knowl-
a pronated or supinated foot might not result from a change in quadriceps muscle activation edge regarding the cause, proper
intensity but from other mechanical factors. ) Orthop Sports Phys Ther 1999;29:93-104. intervention, and prevention of
Key Words: patellofemerol, quadriceps muscle, weight-bearing patellofemoral pain syndrome,
therefore, is essential.
The most common complaint of
patients with patellofemoral pain
syndrome is dull, aching pain in
the anterior aspect of the knee.
Pain can also be noted as being
MI. Hung completed this research in partial fulfillment of his Master of Science degree in Human sharp at times. Hunter1=states that
Movement Science, Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel locking, stiffness, swelling, crepitis,
Hill, NC. and giving way of the knee near
Associate professor, Division of Physical Therapy, University of North Carolina at Chapel Hill, Chap
el Hill, NC:
full extension are other common
Send conesmndence to Michael T: Gross, CB 7135, Division of Physical Therapv, Universityof North symptoms and that these symp
Carolina at'chapel Hill, Chapel Hill, NC 27599-7135. E-mail: m&xs@css.uk.edu toms can be aggravated by j u m p
 ing, kneeling, running with cutting, rising from a subjects. This result indicates that compensatory fem-
chair, climbing steps, weight training, and sitting for oral rotation is more likely to occur than knee joint
a prolonged period with knees flexed. rotation in response to foot position and that the Q
Many factors may be related to the development of angle may actually increase when the tibia internally
patellofemoral pain syndrome: a direct blow to the rotates.
~ a t e l l a , 9 abnormal
. ~ ~ , ~ ~ anatomic factors such as genu Only a few researchers indicate that foot position
v a l g ~ s , 9 .structural
~~.~ abnormalities such as tight can have an impact on quadriceps function. Buch-
harnstrings,P7and patellofemoral malalign- binder et als stated that prolonged foot pronation
ment9J0J7.46.27.P9 Patellofemoral malalignment, includ- can cause internal rotation of the femur and then
ing improper patellar tracking, has been suggested as create an abnormal quadriceps pull on the patella.
the primary cause of patellofemoral pain syn- Gough and Ladleyll studied non-weight bearing i s e
dr~me.".~." metric exercises and reported that the electromyo-
Abnormal anatomic architecture, such as an un- graphic (EMG)activity of the vastus medialis, vastus
even femoral trochlear groove, and medial/lateral lateralis, and the rectus femoris was highest when the
force imbalance may be primary causes of patellofe- foot was dorsiflexed, and neither inversion nor ever-
moral malalignment. The force imbalance can be sion had an impact on the degree of activation. No
due to surrounding structural abnormalities such as study has been conducted to investigate the effects of
a tight lateral retinaculum or muscle force imbal- foot position and weight-bearing exercises on quadri-
ance. On the basis of muscle fiber orientation, the ceps muscle activation. Because the tibia may start to
vastus medialis oblique (VMO) is the primary muscle rotate internally or externally when a subject bears
contributor to the overall medial force vector, and weight on a pronated or supinated foot, it is essential
the vastus lateralis (VL) is the primary muscle con- to examine the relationship between the foot and
tributor to the overall lateral force vector.lg the knee using weight-bearing exercises with the foot
Morphologic deviation and functional deviation placed on the floor.
are the 2 most commonly discussed factors that may We recently conducted a pilot study to examine
alter the balance between the VMO and VL.2J7J931 the effects of foot position on the VMO/VL ratio. A
Morphologically, variations in the physiologic cross- 10" medial/lateral foot wedge was used to elicit a
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sections of the VL and the VMO could influence the pronated foot position and an electronic goniometer
medial/lateral force resultant. Functionally, the patel-
was used to control knee flexion angle. Two healthy
la may also be drawn laterally if the VL is activated
subjects were asked to perform 3 maximum isometric
earlier than the VMO, or the VMO has a relatively
muscle contractions of the quadriceps at full knee
lesser magnitude of activation due to inhibition
extension and 3 short squat exercises from full ex-
caused by pain or s ~ e l l i n g . ~ ~ . ~ ~ . "
tension to 20" of flexion under neutral and pronated
Abnormal foot position has also been suggested as
foot conditions. The VMO/VL ratios were greater for
an important factor that may lead to patellofemoral
malalignment.8J8.P9vs5 Several researcher^^^.^.^^ have the pronated foot condition than the neutral foot
suggested a relationship between foot position and condition for both the isometric muscle contractions
the patellofemoral tracking mechanism. These au- and the short squat activities.
J Orthop Sports Phys Ther 1999.29:93-105.

thors indicate that once a subject bears weight on a Several a u t h ~ r s ~ ~ . ~ . ~suggested

% a v e that foot posi-
pronated foot, the tibia rotates internally. The influ- tion may have a mechanical effect on patellofemoral
ence of this internally rotated tibia on the quadri- joint function. Whether foot position influences pa-
ceps angle ( Q angle) and the medial/lateral force tellofemoral function mechanically or through neu-
balance is unclear. Studies by Huberti14 and Cerny' romuscular activation patterns is unclear. No authors
suggest that when the subject is in a weight-bearing have previously examined the effects of foot position
position with a pronated foot, the tibial tubercle will on the VMO/VL ratio using lowerextremity weight-
shift more medially and also pull the patella medial- bearing exercises. The purpose of this study was to
ly. These authors suggest that a smaller valgus vector investigate more extensively the relationship between
and a smaller Q angle may decrease lateral tracking foot position and 2 quadriceps muscle activation con-
force. D'A~nico,~ T i b e r i ~and
, ~ Power et al,P2howev- ditions: maximum voluntary isometric muscle con-
er, suggest that compensatory femoral internal rota- tractions with the knee extended and 1-leg short
tion may occur with excessive tibial internal rotation, squats with a knee flexion range of motion of 0" to
and both the Q angle and the laterally directed force 50". We chose to perform this preliminary study on
may increase. In an experimental study, Lafortune et healthy subjects before performing more extensive
all8 analyzed knee kinematics for subjects who investigations on patients with symptoms originating
walked with different foot positions: pronated, neu- from knee dysfunction. The specific research ques-
tral, and supinated. They reported that increased in- tion was the following: Do foot position (neutral,
ternal or external tibial rotation caused by different pronated, and supinated) and the 2 muscle activa-
foot positions is resolved at the hip joint in healthy tion conditions significantly influence normalized

J Onhop Sports Phys Ther -Volume 29 Number 2 February 1999

 TABLE 1. Descriptive statistics for men (n = 8), women (n = 8), and pooled sample (n = 16):
Additional
Trials
Rearfoot Arch Leg Length Needed
Age Height Mass Angle Angle Q angle Discrepancy for Short
(Y) (an) (kg) 0 0 0 (cm) Squat
Men 31.9 173.2 62.1 12.4 13.93 16.0 0.5 1.5
+ 6.8 t 4.4 2 7.0 + 2.6 f 11.8 + 3.0 2 0.3 + 1.9
Women 27.0 164.7 59.9 9.9 145.1 19.3 0.3 2 .O
+ 3.3 + 8.6 t 11.1 t 1.9 + 13.9 t 3.4 + 0.3 t 2.2
Pooled Sample 29.4 168.9 61 .O 11.1 142.2 17.6 0.4 1.8
t 5.7 + 8.0 + 9.0 t 2.6 + 12.8 t 3.5 + 0.3 2 2.0
Values are expressed as mean t SD.

VMO activity, normalized VL activity, and the normal-
ized VMO/VL ratio?
METHOD
Subjects
The subjects were 20 healthy volunteers (10 wom-
en, 10 men) ranging in age from 25 to 46 years old.
All subjects had (1) no previous ankle or knee pain
history in the right leg for which they had sought
medical care; (2) no current low back pain or right
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gle.PoAn electronic goniometer (elgon) was used to
monitor knee flexion angle and provide visual bio-
feedback through the oscilloscope. The universal
plastic goniometer was used to calibrate the elgon
from 0" to 50" before each data collection session. A
metronome provided an audio cue to help control
A 10" wedge made of rigid
knee motion velo~ity.~~.~'
material was used to create medial and lateral foot
wedges. The 10" magnitude for the wedge was cho-
sen on the basis of the authors' clinical experience
that this magnitude of wedge is appreciably greater
than most posting configurations that are incorporat-

lowerextremity pain; (3) no skin sensitivity to con- ed into foot orthotics.

ducting gel or adhesive tape; (4) a right foot that
was neither severely pronated nor supinated; and (5)
a palpable VMO and VL when they voluntarily con-
tracted their quadriceps muscles in the sitting posi-
tion. Finally, subjects were not taking pain relief
medicine at the time of testing. Data for 16 of the 20
subjects met the timing and range of motion criteria
for acceptable trials, and descriptive statistics for
these 16 subjects appear in Table 1. The Committee
J Orthop Sports Phys Ther 1999.29:93-105.
Subject Screening Procedure
After each subject read and signed the consent
form, the investigator examined the subject's right
lower leg to determine if the foot was either severely
pronated or supinated. Jonson and Grosd6 suggested
using the rearfoot angle and the longitudinal arch
angle to define people with severely pronated or su-

on the Protection of the Rights of Human Subjects,
the School of Medicine, the University of North Car-
olina at Chapel Hill approved the protocol for this
study.
Instrumentation
Two bipolar silver-silver surface electrodes with
preamplifiers ( X 35), an amplifier ( X 1000), an os-
cilloscope, and a computer were used for EMG data
collection. The EMG signals were transmitted via a
hard wiring system and amplified further by a Thera-
peutics Unlimited GCS.67 (Iowa City, Iowa) electro-
myographic system. The bandwidth of this system is
40 to 4000 Hz with a common mode rejection ratio
of 87 dB at 60 Hz. The input resistance is greater
than 25 MOhms, and the noise is 1.5 mV RMS re-
ferred to input.
We used a 17.8-cm plastic unversal goniometer
with 2" increments and a straightedge caliper to
measure the rearfoot angle and longitudinal arch an-
pinated feet These 2 angles were measured while
the volunteer stood bilaterally with his feet aligned
straight ahead and shoulder width apart The rear-
foot angle is the acute angle formed by the line that
longitudinally bisects the calcaneus and the line that
longitudinally bisects the distal H of the leg. The lon-
gitudinal arch angle is defined as the obtuse angle
formed by the line that connects the medial malleo-
lus and the navicular tuberosity and the line that
connects the navicular tuberosity and the most medi-
al aspect of the first metatarsal head. Jonson and
Gross16 suggested that a foot could be classified as se-
verely pronated if (1) the rearfoot angle was greater
than 12" of eversion and (2) the longitudinal arch
angle was less than 127". A foot could be classified as
severely supinated if (1) the rearfoot angle was great-
er than 0" of inversion and (2) the longitudinal arch
angle was greater than 157'.
The rearfoot angle and the longitudinal arch an-
gle were measured based on the method described
by The subject lay prone with the right leg

J Orthop Sports Phys Ther *Volume 29 Number 2 February 1999


Proximal leg reference line
Distal leg reference line
Proximal aspect of calcaneus
Proximal calcaneus reference line
' Distal calcaneus reference line
FIGURE 1. Four reference lines and leg bisections in the frontal plane
(posterior view) used for drawing lines to measure rearfoot angle.
extended approximately 20 cm off the edge of the
examining table. The subject's left leg was positioned
in hip flexion/abduction/external rotation to keep
the right lower extremity in a neutral rotation. Four
transverse reference lines were drawn perpendicular-
ly to the calcaneus and the distal leg (Figure 1) with
the ankle joint in a relaxed position. The distal calca-
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neal reference line was drawn at its palpated base,
and the proximal calcaneal reference line was drawn
3 cm above the distal calcaneal line. The distal leg
reference line was drawn 6 cm above the palpated
proximal edge of the calcaneus, and the proximal
leg reference line was drawn 8 cm above the distal
line. With the subject remaining in the prone posi-
tion, caliper arms were placed at the medial and lat-
eral calcaneus at the level of the distal calcaneal line.
The principal investigator (Y.H.) applied firm, uni-
form pressure through the calipers on the base of
J Orthop Sports Phys Ther 1999.29:93-105.
the calcaneus and recorded the distance between the
medial and lateral calcaneus. One half of this value
determined the bisection mark. The remaining 3 bi-
section marks were determined with the subject
standing. The rearfoot angle was measured as the
acute angle formed by the line that connected the
distal calcaneal bisection mark and the proximal cal-
caned bisection mark and the line that connected
the distal leg bisection mark and the proximal leg bi-
section mark.
With the subject remaining in the standing posi-
tion, the medial malleolus, navicular tuberosity, and
the most medial aspect of the first metatarsal head
were marked. The longitudinal arch angle was mea-
sured as the obtuse angle formed by the line that
connected the medial malleolus and the navicular tu-
berosity and the line that connected the navicular tu-
berosity and the most medial aspect of the first meta-
tarsal head. In addition to other exclusion criteria,
the subject's qualification for the study was deter-
mined based on the rearfoot angle and longitudinal
arch angle measurements. Persons with a severely
pronated or supinated foot did not qualify for the
study. All 20 volunteers recruited for the study quali-
fied on the basis of the selection criteria.
After the subject was evaluated for inclusion in the
study, 2 additional measurements were taken. With
the subject in the supine position, the leg length was
measured from the anterior superior iliac spine to
the medial malleolus. In addition, with the subject
standing, each subject's Q angle was measured as the
acute angle formed by the line that connected ante-
rior superior iliac spine and the center of the patella
and the line that connected the center of the patella
and the tibial tuber~le.~' We also recorded each s u b
ject's age, gender, mass, and height.
Subject Preparation
Each subject then had the hair shaved over the
electrode sites on the right leg, if necessary, and the
electrode sites were cleaned with alcohol. Double-sid-
ed adhesive tape and conducting gel were applied to
both surface electrodes, and the electrodes were a p
plied to the subject. The surface electrode for the
VMO was placed at the most prominent portion of
and the electrode for the VL
the muscle belly,P1~PS~s3
was placed over the muscle belly at a point 40%
from the lateral knee joint line to the greater tro-
chanter. Both electrodes were aligned parallel with
muscle fiber orientation. According to Lieb et al,19
the muscle fibers of the VMO insert onto the patella
at a more oblique angle (50" to 55") than the fibers
of the VL (12" to 15"). An electronic goniometer was
applied to the lateral side of the subject's right knee
by attaching 1 arm of the goniometer to the leg and
the other arm to the thigh, with the goniometer axis
aligned with the lateral femoral condyle.
Testing Procedure
Before data collection procedures began, each s u b
ject received both a verbal explanation and a demon-
stration of the testing activities. With the subject's
bare foot aligned straight ahead, the subject was test-
ed for maximum voluntary isometric quadriceps mu*
cle contractions and 1-leg short squats of the right
lower extremity under 3 foot conditions: level sur-
face, a 10" medial wedge, and a 10" lateral wedge.
Testing for the supinated foot condition involved
placing the subject's right foot on the 10" medial
wedge so that the lateral border of the foot was
aligned along the thinner edge of the wedge. Testing
for the pronated foot position involved placing the
subject's right foot on the 10" lateral wedge so that
the medial border of the foot was aligned along the
thinner edge of the wedge. Because 6 possible test-
ing orders existed for the sequence of the 3 foot
J Orthop Sports Phys Ther .Volume 29 Number 2 February 1999
 conditions, each subject was systematically assigned to
a possible testing order to ensure that each of the
possible testing sequences was represented equally.
The EMG electrodes and the electronic goniome-
ter were applied to the subject before the subject
practiced the testing sequence. To orient each sub-
ject to general testing procedures, the subject first
performed 1 practice trial of the maximum voluntary
isometric quadriceps muscle contraction on a level
surface at full knee e x t e n s i ~ n Each
. ~ ~ maximum vol-
untary isometric quadriceps muscle contraction was
maintained for 4 seconds.
To calibrate the knee flexion angle for the short
squat, the subject first performed 1 short squat on a
level surface. The subject was asked to flex the right
0.0 I I
knee to 50" of knee flexion, then return to full knee Onset Offset
extension while watching the oscilloscope. The sub- Time
ject then practiced short squats from 0" to 50" of
FIGURE 2. The electromyographic data of 1 short squat trial with onset
knee flexion while watching the oscilloscope and lis- and offset event boundaries determined from the electrogoniometer(elgon
tening to the metronome to control the pace of the signal), which is scaled at 10"ldivision. VMO = vastus medialis oblique
squat motion. The duration of each short squat was scaled at 0.07 Volts/division, VL = vastus lateralis scaled at 0.02 Volts/
4 seconds--:! seconds for descending and 2 seconds division, 800 ms/division on horizontal axis. Downward deflection on the
for ascending. The subject was asked to lift the left goniometer indicates knee flexion.
leg slightly off the ground while performing the task.
At least 3 practice trials for the short squat were re- minute rest between data collection for the remain-
quired for the subject to control synchronously both ing 2 foot conditions. If the prescribed testing order
the squat pace and knee flexion range of motion. started with the level surface condition, then the sub-
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The investigator monitored the subject's perfor-
mance qualitatively on the basis of the metronome
and knee elgon signals and decided how many addi-
tional trials would be needed for each subject to per- square processing using a time constant of 20 ms.
form the squat task appropriately. Each subject was
required to perform 2 successive trials appropriately
to demonstrate the ability to perform the task ac-
cording to the range of motion and timing criteria.
Any additional trials needed for the subject to per-
form acceptable short squats were documented. For
both the maximum voluntary isometric quadriceps
J Orthop Sports Phys Ther 1999.29:93-105.
ject only performed the initial general practice trials
before data collection for the level surface condition.
The EMG data initially underwent root mean
The root mean square signals for the VMO and VL
were then sampled at 500 Hz through an analog-te
digital converter using Datapac software.1S~21~2~zR
The principal investigator first analyzed the calibra-
tion trial and all of the short squat trials to deter-
mine the onset and offset of each event by monitor-
ing the voltage change of the elgon signals (Figure

muscle contraction and the short squat, the subject's 2). Onset and offset were identified qualitatively by
hand position was not constrained. After the practice judging the departure of the elgon signed from its 0"
trials, the subject sat down and rested for 2 minutes. baseline and its return to baseline voltage (Figure 2).
Each subject then performed practice and data
collection trials for each of the 3 foot conditions in
For the calibration trial, the maximum elgon voltage
represented 0" of knee flexion and the minimum el-
l~
1.
1

m i
the order determined by the systematic variation pro- gon voltage represented 50" of knee flexion. On the
cedure. For each foot condition, the subject prac- basis of the calibration trial, the differences between
1 fl
ticed the testing procedures using the same protocol
for the general practice described previously. The
subject was then asked to perform 3 maximal volun-
tary isometric contractions of the quadriceps at full
the maximum and minimum elgon voltages for the
short squat trials were then calculated and used to
determine the minimum and maximum knee flexion
angles for each short squat trial. The onset and off-
knee extension for data collection. The subject main- set for each event were recorded, and the duration
;1 i!
1/ =:
;j
tained each maximum voluntary isometric quadri- for each event was then calculated. Acceptable short
ceps muscle contraction for 4 seconds and rested for squat trials were defined by both timing and knee
30 seconds between each trial. After a 1-minute rest, range of motion criteria. An acceptable short squat
the subject was asked to perform 5 short squats while trial involved the squat duration being 4 -C 0.5 sec-
viewing the oscilloscope output to control the knee onds. An acceptable trial also involved the knee flex-
flexion angle from 0" to 50" of knee flexion. The ion range of motion occurring between 0" 2 5" and
c -
subject had a 30-second rest period between each 50" -C 5". I i
short squat trial. Each subject had an additional 2- The principal investigator then analyzed the maxi- iidid

J Onhop Sports Phys Ther.Volume 29 Number 2 February 1999


Yo1 tage
I I I I ,
0.0
Onset Offset
Tim
FIGURE 3. The electromyographicdata of 1 maximum voluntary isometric
quadriceps muscle contractiontrial with onset and offset event boundaries.
VMO = vastus medialis oblique scaled at 0.12 VolWdivision, VL = vastus
lateralis scaled at 0.35 Voltddivision, 800 mddivision on horizontal axis.
Elgon signal is scaled at 1.8°/division.
mum voluntary isometric quadriceps muscle contrac-
tion trials by monitoring only the EMG signals for
both the VMO and VL (Figure 3). For each maxi-
mum voluntary isometric quadriceps muscle contrac-
tion, the onset of the event was chosen when both
muscles started to contract, judged qualitatively as
Downloaded from www.jospt.org by 151.135.200.115 on 12/22/18. For personal use only.
departure of the rectified EMG signals from resting
baseline. Offset of the event was chosen 4 seconds af-
ter the onset. For maximal isometric contractions,
the EMG data for the first second were not used for
analysis. We chose not to select the first 1-second
window of data for analysis because we thought that
this would be a period during which each subject
would be recruiting additional motor units and in-
creasing the rate of depolarization of the motor units
that had already been recruited. The data of the oth-
er 3 seconds were partitioned into 1-second intervals.
J Orthop Sports Phys Ther 1999.29:93-105.
Only the l-second interval with the maximum mean
amplitude for each muscle was selected for data anal-
ysis for each trial.I5 For the short squat, the data
from the beginning to the end of the movement
were analyzed by computing the mean root mean
square amplitude.
The l-second intervals with the maximum ampli-
tude for each of the 3 trials at the neutral foot posi-
tion was computed for the VMO amplitude and the
VL amplitude. The mean VMO and the mean VL val-
ues were used to normalize all EMG data for all foot
positions and both activities. To normalize the raw
VMO EMG, the mean VMO EMG amplitude of the 3
trials was calculated first and then divided by the
normalized VMO value described previously. The
same calculation was repeated for all foot positions
and both activities (6 combinations in total). The
same method was also used to normalize all of the
VL EMG. The VMO/VL ratios were then calculated
on the basis of the normalized data. The mean of
the VMO/VL ratios for 3 trials was calculated for
each activity at the different foot positions.
Data Analysis
Intraclass correlation coefficient analyses (ICC
[3,3]) were used to test the reliability of the VMO/
VL ratio among 3 trials at each foot position for
both activities. The data of 10 randomly chosen s u b
jects (5 women, 5 men) were used for the ICC analy-
ses. Those subjects' normalized VMO/VL ratios for
all of the foot positions and both the activities were
analyzed. The ICC analyses tested the consistency
among 3 trials for each of the 6 testing scenarios (3
foot positions X 2 activities). Separate 2-way ANOVA
procedures with repeated measures on both factors
were conducted to determine the effects of foot posi-
tion and muscle activation condition on the normal-
ized VMO data, the normalized VL data, and the
normalized VMO/VL ratio. We also conducted post
hoc power analyses.
RESULTS
Only 16 of the 20 subjects who participated in the
study had at least 3 trials of the short squat at each
foot position that met the timing and range of mo-
tion acceptance criteria. Only the data for these 16
subjects, therefore, were analyzed. The 4 subjects
whose data were excluded from the statistical analy-
ses all failed to meet the acceptable knee range of
motion criteria.
The ICC reliability results for the maximum volun-
tary isometric quadriceps muscle contraction and the
short squat at different foot positions are presented
in Table 2. All ICC values were greater than 0.94 ex-
cept for the MVIC testing with the neutral foot posi-
tion (ICC = 0.63).
Descriptive statistics for the effects of activity and
foot position on normalized VMO EMG and on nor-
malized VL EMG are shown in Figures 4 and 5, re-
spectively. Figure 6 shows descriptive statistics for the
effects of activity and foot position on the normal-
ized VMO/VL ratio. The interaction between type of
foot position and activity was not statistically signifi-
TABLE 2. lntraclass correlation coefficient results (ICC[3,31) for the maxi-
mum voluntary isometric quadriceps muscle contraction and short squat
at different foot positions.
Neutral Supinated Pronated
Variable Foot Foot Foot
Maximum voluntary
isometric contraction 0.63 0.94 0.95
Short squat 0.97 0.97 0.97
Values represent the reliability of the normalized vastus medialis oblique1
vastus lateralis (VMOIVL) electromyographic ratio across 3 test trials.
ICC(3,3) = (Between Mean Square-Error Mean Square)/Between Mean
Square.
J Orthop Sports Phys Ther .Volume 29 Number 2 February 1999
 1.4- 1.4-

-
A

g=
s
Y
1.2

1.0-

0.8
-

-
MVIC
1 -
g
=;F
-
1.2

1.0-

0.8
MVIC
T
= -
Y

Q
0.6 - Short Squat
Q
W
0.6
Short Squat
0
$ 0.4-
>
0.2 0.2 -
I I I I I I I I
Suplnated Neutral Pronatrd Suplnated Neutral Pronated

Foot Porition Foot Porltion

FIGURE 4. The effects of activity and foot position on normalized vastus FIGURE 5. The effectsof activity (short squat and MVIQ and foot position
medialis oblique (VMO) electromyography.Values are means with standard on normalized vastus lateralis (VL) electromyography. Values are means
deviation bars represented. MVIC = maximum voluntary isometric muscle with standard deviation bars represented. MVlC = maximum voluntary
contraction. isometric muscle contraction.

cant in any of the 3 ANOVA analyses. We did not
identify any significant differences across the 3 foot
positions. We did find, however, significant differ-
ences between the 2 activities. Normalized VMO (F
= 34.07; df = 1, 15; P < .05) and VL (F= 122.04; df
= 1, 15; P < .05) EMG amplitudes were significantly
greater during the maximum voluntary isometric
Downloaded from www.jospt.org by 151.135.200.115 on 12/22/18. For personal use only.
among subjects for this testing condition may have
contributed to the lower ICC value for the normal-
ized VMO/VL ratios for the maximum voluntary iso-
metric quadriceps muscle contraction at the neutral
foot position. To clarify this issue, further ICC testing
of the raw VMO EMG and the raw VL EMG among
the 3 trials was conducted for the maximum volun-

quadriceps muscle contraction than during the short
squat. The normalized VMO/VL ratio, however, was
significantly greater (F= 7.73; df = 1, 15; P < .05)
during the short squat than during the maximum
voluntary isometric quadriceps muscle contraction.
Power values for the nonsignificant effects of foot po-
sition ranged between 0.06 and 0.12 for the 3
ANOVA analyses.
Reliability
J Orthop Sports Phys Ther 1999.29:93-105.
tary isometric quadriceps muscle contraction data for
the neutral foot position. The ICC (3,3) results for
the raw VMO EMG and the raw VL EMG data were
0.96 and 0.97, respectively. The ICC results generally
suggest good reliability for the EMG data.
DISCUSSION
The study was designed mainly to provide informa-
tion regarding the effects of foot position on quadri-

The consistency among 3 trials was examined us-

ing ICC analyses. For the short squat, reliability (ICC Short Squat
= 0.97) was good among trials for all foot positions.
1.2
Reliability was good for the maximum voluntary iso-
metric quadriceps muscle contraction for the supi-
nated and the pronated foot positions (ICC = 0.94
and 0.95, respectively), but was poor for the maxi-
mum voluntary isometric quadriceps muscle contrac-
tion for the neutral foot position (ICC = 0.63). One
possible reason for the poor ICC value might be that
the VMO/VL ratios were very similar among the s u b
jects for the neutral foot position. Because of the
normalizing process, each subject's raw VMO and VL
EMG for each trial was divided by the mean of the 3
maximum voluntary isometric quadriceps muscle Suplnatad Neutral Pronated
contraction trials for the neutral foot position. This Foot Podtion
tended to make all of the normalized maximum vol-
FIGURE 6. The effects of activity (short squat and MVIQ and foot position
untary isometric quadriceps muscle contraction data on normalized vastus medialis obliqudvastus lateralis (VMONL) ratio.Va1-
for the individual neutral foot position trials close to ues are means with standard deviation ban represented. MVlC = maxi-
1.0 in value. The resulting decrease in variability mum voluntary isometric quadriceps muscle contraction testing condition.

J Onhop Sports Phys Ther *Volume29 Number 2 February 1999 99

 ceps muscle activation intensity. The results indicate
that the 3 foot positions did not affect the normal-
ized VMO EMG, normalized VL EMG, and the nor-
malized VMO/VL ratio. No authors have previously
examined the effects of foot position on the VMO/
VL ratio using lowerextremity weight-bearing exercis-
es. Several r e s e a r ~ h e r s , ~ - *however,
' . ~ ~ , ~ ~have suggest-
ed a relationship between foot position and the pa-
tellofemoral tracking mechanism. Buchbinder et als
have even suggested that foot position could have a
direct impact on the quadriceps force vector. Al-
though the power values for the nonsignificant ef-
fects of foot position were low, the very similar EMG
E
values among foot positions for each analysis suggest o MVlC Short Squat
Z
that foot position may not influence quadriceps mus-
cle activation intensities. Activity
Eng and Pierrynowski8 reported a significant de- FIGURE 7. The effects of activity on normalized vastus medialis oblique
crease in pain using a foot orthotic to treat patellofe- (VMO) and vastus lateralis (VL) electromyography. MVlC = maximum vol-
moral pain in patients who had pronated feet. Be- untary isometric quadriceps muscle contraction testing condition.
cause our results suggest that foot position might
have no effect on quadriceps muscle activation inten- VMO and VL activations that approximated 40% to
sity, other factors imposed by foot position may influ- 45% of the maximum voluntary isometric muscle
ence patellofemoral joint function (ie, medial/lateral contractions. Further research is necessary to deter-
force resultant). Eng and Pierrynowskie suggested mine if this or greater levels of training intensity
that the need for forward propulsion, shock absorp- would result in desirable outcomes for patients with
tion, and the Q angle are altered by different foot patellofemoral pain syndrome.
positions. The influence on the knee and hip joints This study has certain limitations. The results may
Downloaded from www.jospt.org by 151.135.200.115 on 12/22/18. For personal use only.

caused by different foot positions is not clear in the not be generalized to patients with excessively pro-
literature. Lafortune et al,18 however, reported that nated or supinated feet or to patients with patellofe-
in healthy subjects, increased internal or external tib- moral pain syndrome. Future studies using patients
ial rotation caused by different foot positions is re- with excessively pronated or supinated feet and pa-
solved at the hip joint rather than the knee joint. An tients with patellofemoral pain syndrome are needed.
internally or externally rotated femur may change The results also may have differed if we had used
the Q angle, which might indirectly change patellofe- each subject's preferred t o e - i n / t o ~ u tposition. Be-
moral joint mechanics. cause each subject was asked to relax during the pro-
Several researchers1@have suggested the use of iso- cedure for placing the horizontal reference marks on
metric quadriceps exercises to treat patellofemoral the posterior aspect of the leg and heel, ankle joint
pain syndrome. Some researcher^,^"^^ however, advo- position was not standardized among the subjects
J Orthop Sports Phys Ther 1999.29:93-105.

cate the use of weight-bearing activities for patients during this procedure. Failure to standardize ankle
with patellofemoral pain syndrome. Our results indi- joint position may have influenced the screening
cate that the decrease in EMG between the maxi- measurement of rearfoot angle. Because we only ex-
mum voluntary isometric quadriceps muscle contrac- amined subjects who performed the maximum vol-
tion and the short squat for the VMO is less than the untary isometric quadriceps muscle contraction and
decrease for the VL (Figure 7). These relationships short squat, altering foot position may have some in-
resulted in the normalized VMO/VL ratio being sig- fluence on other dynamic movements such as walk-
nificantly greater during the short squat than during ing and stair climbing. We also did not document
the maximum voluntary isometric quadriceps muscle that the wedge intervention actually caused a change
contraction. The reason for the difference is not in structural alignment of the lower extremity. As we
clear. This result, however, may indicate that the indicated previously, however, we chose the 10" mag-
short squat exercise within pain-free range of motion nitude for the wedge on the basis of our clinical ex-
may be more effective in selective strengthening of perience that this magnitude of wedge is appreciably
the VMO than the maximal isometric quadriceps greater than most posting configurations that are in-
muscle contraction with the knee fully extended. corporated into foot orthotics.
This factor may be important for patients whose pa-
tellofemoral pain syndrome is related to an imbal- CONCLUSION
ance of patellofemoral muscle forces. Related to this
issue of selective strengthening of the VMO are the Our results suggest that foot position (neutral, pro-
results that the short squat exercise we used caused nated, and supinated foot) may not have a signifi-

J Orthop Sports Phys Ther .Volume 29. Number 2 February 1999

 cant effect o n quadriceps muscle activation intensi-
ties f o r healthy subjects. Clinicians should under-
stand that the benefit o f using a foot orthotic to cor-
rect a pronated o r supinated foot f o r patients with
patellofemoral pain syndrome might n o t result f r o m
a change in quadriceps muscle activation intensities
but f r o m other mechanical factors. T h e results also
indicate that the normalized VMO/VL ratios are sig-
nificantly greater during the short squat than the
maximum voluntary isometric quadriceps muscle
contraction. This result may indicate that the short
squat exercise within pain-free range o f m o t i o n may
be more effective in selective strengthening o f the
VMO than the maximal isometric quadriceps muscle
contraction with the knee fully extended.
ACKNOWLEDGMENTS
T h e authors thank Carol Giuliani, PhD, PT and
Jon Hacke, MS, PT,ATC f o r their contributions t o
this study.
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J Orthop Sports Phy ThereVolume 29eNumber 2-February 1999
 Invited Commentary
Hung and Gross have elected to make a contribu-
tion to the literature on the topic of quadriceps mus-
cular control for those with alterations of the foot as
related to patellofemoral dysfunction. As noted by the
authors, the etiology of patellofemoral joint dysfunc-
tion can be extremely varied. Further, the "hard evi-
dence" for the cause of the chief complaint of pain
in the anterior knee is minimal. Most studies only
speculate about the true cause, and there are many
speculated causes. This makes the problem difficultto
approach unless investigators can establish the true
cause, which may be inappropriate muscle action.
Only then will we be able to apply the appropriate
correctional action. To be even more precise, we
would need to determine whether the intensity or
timing or both were at fault in the sample of subjects
identified for testing.
It is possible, however, to provide intuitive argu-
ments that the mechanics of the foot alter the m e
chanics at the knee, including the patellofemoral
Downloaded from www.jospt.org by 151.135.200.115 on 12/22/18. For personal use only.
joint. Because establishing that the foot mechanics
may somehow be linked to patellofemoraljoint dys
function, it is disappointing that this article does not
include a study of this issue or a compelling argument
that foot position can have an effect on vastus medi-
alis oblique (VMO)or vastus lateralis (VL) function as
measured by an electromyograrn (EMG).
If the premises of the authors or causality of the
dysfunction can be assumed, the next focus needs to
be on the methodology of the study. Several procedu-
res raise some questions. For example, what is the ra-
J Orthop Sports Phys Ther 1999.29:93-105.
tionale for the selection of the single-limb weight-bear-
ing squat as the exercise of choice? Also, why is the
maximum voluntary isometric muscle contraction
(MVIC)for the quadriceps muscles done in the stand-
ing position? Further, what is the clinical relevance of
a lodegree wedge as opposed to a posted foot orthot-
ic that is more likely to be used clinically? What is the
validity of the method used for determining whether
subjects have a pronated or supinated foot? The read-
er also expects the discussion to include comments
about the Q angle and leg length because these mea-
surements are made by the investigators.
Of all of these issues, the most important is proba-
bly the test position for the MVIC.Usually this con-
traction is done while supine or in the long-sitting p e
sition. Performing this contraction while standing may
inhibit the quadriceps. The subject may inhibit the
quadriceps voluntarily or the joint receptors may p r e
vide input that minimizes hyperextension of the joint
A comparison of MVICs across these 2 positions
J Orthop Spow Phys Ther .Volume 29 Number 2 February 1999
would lend credibility to the comparisons made in the
discussion portion of this paper.
The analytic techniques used in this study may also
have had an effect. For example, ruling out the first
second of the EMG from the MVIC apparently alters
the results. This supposition is based on Figure 3,
which shows the maximum EMG in the very early
part of the contraction interval. Regardless of recruit-
ment and rate-firing issues, this is still the interval
when the maximum EMG is evoked. Further, why
would we expect the maximum to occur during one
of the other 1-second intervals? A sounder method
would be to have the computer search for the highest
RMS value for the interval of time selected. In most
studies this interval has arbitrarily been set at 3 sec-
onds rather than at 1 second. The advantage is the
authors', however, because their analysis is all based
on comparison of other data to the same normalized
value. This procedure of normalization is necessary
and commendable relative to the analytic procedures
used in this study. Of additional interest is that the in-
vestigators chose to use a k c o n d interval of eccen-
tric and concentric contractions to compare to the
MVIC.Are the comparisons made just as valid even
though the muscle undergoes length change over a
different period of time than that for the isometric
maximum contraction? Should we be suspicious that
the differences noted between the MVIC and the
short squat are because of confounding factors rather
than any joint mechanics occurring, particularly at the
patellofemoraljoint? Including this issue in the discus-
sion section of the article would make for a more
comprehensive work.
The conclusion that the VMO/VL ratios are signifi-
cantly greater during the short squat than the MVIC
also needs comment. If a different EMG value was
generated from the MVIC as a result of a diierent
test position, this finding would not hold true, a point
not to be trivialized. Further, the 40% to 45% of acti-
vation of the muscles relative to the MVIC would also
be altered. Finally, as the authors state, we need to
conduct studies of patients with known mechanical
aberrations so that we can provide the clinical com-
munity with more definitive treatment protocols that
are likely to be successful.
Gary L. Soderberg, PT,PhD, FAETTA
Professor of Physical Therapy
University of Central Arkansas
Physical Therapy Center, Suite 100
201 Donahey
Conway, AR 72035
 Author Response
We thank Dr. Soderberg for his constructive review
of our paper. Dr. Soderberg has raised many substan-
tive issues, some of which were addressed in our re-
search report. We hope the response that follows will
clarify for the reader information included in the re-
port and other issues raised by Dr. Soderberg.
Dr. Soderberg first questions the link between foot
position and patellofemoral joint dysfunction, indi-
cating that we neither studied this issue nor provided
a compelling argument that foot position can have
an effect on quadriceps muscle activation intensities.
We assume he makes this observation on the basis of
our attempts to lay the foundation for our study. We
did indicate in the last 2 paragraphs of the introduc-
tion that several authors have suggested that foot po-
sition may have a mechanical effect on patellofemor-
a1 joint dysfunction. This issue has not been studied
systematically, but support for this relationship exists
when clinicians observe that patellofemoral joint dys-
function can be treated successfully using foot or-
thotics and shoewear designed to control foot me-
Downloaded from www.jospt.org by 151.135.200.115 on 12/22/18. For personal use only.
c h a n i c ~ .We
~ . ~also indicated that the only basis for
investigating the influence of foot position on quad-
riceps muscle activation intensities was pilot work by
Mr. You-joi Hung, the principal investigator, suggest-
ing that some causal relationship existed.
Dr. Soderberg raises several questions related to
method. The rationale for selecting the single-limb
weight-bearing squat relates to the functional tasks
during which patellofemoral pain is often elicited.
Symptoms of pain, swelling, and stiffness can be ag-
J Orthop Sports Phys Ther 1999.29:93-105.
gravated by ascending and descending stairs, j u m p
ing, and running (second paragraph of article). We
also thought that single-limb weight-bearing would
elicit greater muscle activation intensities than a bi-
lateral squat activity and would enable better control
of magnitude of weightbearing across the different
foot positions.
Several questions also relate to the maximum vol-
untary isometric muscle contraction (MVIC) being
performed in standing as opposed to other positions.
We are not sure that performing the MVIC in other
positions would address the issues of using an isomet-
ric muscle contraction to normalize concentric and
eccentric muscle contractions that involve changes in
length-tension and force-velocity relationships, as well
as the issue of movement of muscle tissue under the
surface electrodes. We selected the standing position
for the MVIC because all of the EMG data collection
procedures involved weight-bearing tasks for the s u b
jects. We also wanted some method for describing
the relative magnitude of the muscle activation inten-
sities during the single-limb squat activity under vary-
ing foot positions. As we indicate in the paper, the
main purpose of the project was to investigate the ef-
fects of foot position on quadriceps muscle activation
intensities. The contrasts among foot positions all in-
volved a within-subjects design. We do not believe
that use of a different normalizing muscle contrac-
tion would have changed any of the results that relat-
ed to the effects of foot position on EMG values.
Another issue raised by Dr. Soderberg relates to
the selection of the time window for analysis of the
maximum voluntary isometric EMG data. We did not
want to select the first l-second window of data be-
cause we thought that this would be a period during
which each subject would be recruiting additional
motor units and increasing the rate of depolarization
of the motor units that had already been recruited
(next to last paragraph of testing procedures). Al-
though some of the higher RMS peaks in Figure 3
occur during the first 1-second window, these peaks
take place toward the end of this l-second period.
Most of the first 1-second window of data suggests a
gradual increase in both recruitment and rate of de-
polarization. Additionally, our method of data reduc-
tion has been used previously,' and the ICC results
demonstrate unusually good reliability for the MVICs
of the VMO (ICC = 0.96) and the VL (ICC = 0.97).
The method for classifying foot type was suggested
in a previous publication.' Several previous investiga-
tors have used the longitudinal arch angle2.' and
rearfoot to leg angles.8e9to assess the degree to which
clinicians might evaluate a foot as relatively pronated
or supinated.
Mr. Hung's pilot work served as the basis for using
a 10" wedge (introduction). We also chose to "push
the issue" and determine if, in this initial foray into
the general research question, a wedge that was larg-
er than clinical posts used in foot orthotics would
have some effect on quadriceps muscle activation in-
tensity (last sentence of the instrumentation section).
Finally, we chose to include measurements of s u b
jects' Q angle and leg length inequality solely as de-
scriptors of the subjects who participated in the
study.
Again, we thank Dr. Soderberg for his critical and
constructive review of our research report. We also
thank the Editor of the Journal for this forum for
discussing current research reports and stimulating
thoughts on future research endeavors.
You-jou Hung, PT, MS
Michael T. Gross, PT, PhD
J Orthop Sports Phys Ther *Volume 29 Number 2 February 1999

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