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Computational biomechanics of knee joint in open kinetic chain extension

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Computer Methods in Biomechanics and Biomedical Engineering,
Vol. 11, No. 1, February 2008, 55–61

Computational biomechanics of knee joint in open kinetic chain

extension exercises
W. MESFAR and A. SHIRAZI-ADL*

Division of Applied Mechanics, Department of Mechanical Engineering, École Polytechnique, Montréal, Que., Canada

Open kinetic chain (OKC) extension exercises are commonly performed to strengthen quadriceps
muscles and restore joint function in performance enhancement programs, in exercise therapies and
following joint reconstruction. Using a validated 3D nonlinear finite element model, the detailed
biomechanics of the entire joint in OKC extension exercises are investigated at 0, 30, 60 and 908 joint
angles. Two loading cases are simulated; one with only the weight of the leg and the foot while the
second considers also a moderate resistant force of 30 N acting at the ankle perpendicular to the tibia.
The presence of the 30 N markedly influences the results both in terms of the magnitude and the
trend. The resistant load substantially increases the required quadriceps, patellar tendon, cruciate
ligaments and joint contact forces, especially at near 908 angles with the exception of ACL force that is
increased at 08 angle. At post-ACL reconstruction period or in the joint with ACL injury, the exercise
should preferably be avoided at near full extension positions under large resistant forces.

Keywords: Open kinetic chain; Extension exercise; Knee joint; Finite elements; Ligaments;
Quadriceps

1. Introduction
The human knee joint is recognized as a complex,
vulnerable and highly loaded joint with strong interactions
between its various active and passive components. In the
event of a weakness, injury or surgical reconstruction of a
component, the compensatory biomechanical role of
remaining intact structures alters predisposing the joint to
risk of additional degenerations and injuries. Various
rehabilitation exercises are currently used in non-operative
and post-operative managements of joint disorders.
Athletic training and performance enhancement programs
also exploit of such exercises. Evidently, the challenge
is to exercise and strengthen the muscles and restore
the near-normal function of the joint while protecting it
(e.g. the reconstructed ligament) from excessive stresses
that may be generated during such exercises.
The open kinetic chain (OKC) and closed kinetic chain
(CKC) exercises generate, as expected, different patterns
of muscle activities and ligament forces in the knee joint
(Wilk et al. 1996, Escamilla et al. 1998). Biomechanical
and clinical investigations have suggested that OKC
extension exercises produce large forces in the anterior
cruciate ligament (ACL) especially near full extension
(Smidt 1973, Henning et al. 1985, Jurist and Otis 1985,
Shoemaker and Markolf 1985, Draganich et al. 1987,
Yasuda and Sasaki 1987, Kaufman et al. 1991, Yack et al.
1993, Escamilla et al. 1998). In contrast, CKC exercises
have been recommended to be safer in post-ACL
reconstruction period (Henning et al. 1985, Shelbourne
and Nitz 1990, Palmitier et al. 1991, Lutz et al. 1993,
Yack et al. 1993, Bynum et al. 1995, Fitzgerald 1997).
More recent studies have, however, advocated both OKC
and CKC exercises as effective ways to restore and
enhance performance of joint normal function (Fitzgerald
1997, Rogol et al. 1998, Witvrouw et al. 2000, 2004,
Hooper et al. 2001, Ross et al. 2001, Heintjes et al. 2003,
Fleming et al. 2005, Perry et al. 2005a,b, Andersen et al.
2006). Using a combined model-measurement study,
Cohen et al. (2001) reported that the patellofemoral (PF)
contact stresses were of the same order of magnitude in
both OKC and CKC exercises.
When modelling OKC extension exercises, forces in
quadriceps muscles were reported to alter with both the
knee joint flexion angle and the resistant force on the foot
(Grood et al. 1984, Shelburne and Pandy 1997, Cohen
et al. 2001). Grood et al. (1984) measured the quadriceps
forces required to counterbalance the moment of gravity

*Corresponding author. Email: abshir@meca.polymtl.ca

Computer Methods in Biomechanics and Biomedical Engineering

ISSN 1025-5842 print/ISSN 1476-8259 online q 2008 Taylor & Francis
http://www.tandf.co.uk/journals
DOI: 10.1080/10255840701552028
56 W. Mesfar and A. Shirazi-Adl

with and without a 31 N weight at the foot. They reported
quadriceps forces that remained nearly unchanged at 15–
508 flexion range but substantially increased or decreased
towards full extension or 908 flexion, respectively. In clear
contrast to these findings, Cohen et al. (2001) measured
quadriceps forces that increased consistently with joint
flexion angle when under 25 or 100 N loads applied
perpendicular to the tibia at the ankle. Under gravity
alone, they reported smaller quadriceps forces that
remained nearly constant in the range of 20 –808. Using
a 2D sagittal model of the knee, Shelburne and Pandy
(1997) simulated the quadriceps leg raise experiment of
Grood et al. (1984) and predicted quadriceps forces that
also remained constant in the 15 – 608 flexion range but
differed near full flexion and full extension angles.
In our earlier model studies of the entire knee joint, we
computed the detailed joint response at different flexion
angles under various flexor – extensor muscle loads,
boundary conditions, cruciate ligament prestrains and
cruciate ligament material properties (Mesfar and Shirazi-
Adl 2005, 2006a,b). In these studies, however, the
magnitude of forces in quadriceps and/or hamstrings
remained constant throughout joint flexion from 0 to 908
and the weight of the leg and foot was neglected. In the
absence of a thorough study on the biomechanics of both
tibiofemoral (TF) and PF joints in OKC extension
exercises, this work aimed hence to employ our previously
validated 3D knee model to investigate the detailed
biomechanics of the entire joint in OKC extension
exercises. Two loading cases were simulated; one with no
external load accounting only for the weight of the leg and
the foot while the second also incorporated a moderate
resisting force of 30 N acting at the ankle perpendicular to
the tibia. For the joint angles of 0, 30, 60 and 908, the
detailed biomechanics of both TF and PF joints including
required quadriceps forces, joint moment, patellar tendon
(PT) force, extensor lever arm, PF and TF contact forces
and joint ligament forces were computed.
2. Method
Three bony structures (tibia, femur and patella) and their
articular cartilage layers, menisci, six principal ligaments
(medial/lateral collaterals MCL/LCL, anterior/posterior
cruciates ACL/PCL and medial/lateral PF ligaments
MPFL/LPFL), PT, quadriceps muscle force vectors
(divided into three components; vastus lateralis, VL/
rectus femoris-vastus intermidus medialis, RF-VIM/vas-
tus medialis obliqus, VMO) are considered in the model of
the entire knee joint (figure 1). Forces in quadriceps
components are selected according to the ratios of their
physiological cross-sectional areas VMO:RF/VIM:VL ¼
2:3:2.5 (Mesfar and Shirazi-Adl 2005). The direction of
the force in each component is derived from the Q angle
model (Q angle ¼ 148; Sakai et al. 1996). In the frontal
plane, the direction of RF/VIM is parallel to the femoral
axis, the VMO is 418 medially, and the VL 228 laterally. In
the sagittal plane, RF/VIM is 48 anterior to the femoral
axis whereas the VMO and VL are oriented parallel to the
femoral axis. Ligaments are each modelled by a number of
uniaxial elements with different prestrains and nonlinear
material properties (no compression), (Butler et al. 1986,
Stäubli et al. 1999, Atkinson et al. 2000, Moglo and
Shirazi-Adl 2003a,b, Mesfar and Shirazi-Adl 2005,
2006a,b).
The articular cartilage layers are homogeneous
isotropic with elastic modulus of 12 MPa and Poisson’s

Figure 1. Finite element model of the entire knee joint showing cartilage layers, menisci, ligaments, PT, quadriceps muscles. Bony structures are only
indicated by their primary nodes. Quadriceps components considered are VMO: vastus medialis obliqus, RF: rectus femoris, VIM: vastus intermidus
medialis and VL: vastus lateralis. On the left, gravity and resistant forces are also schematically shown. LPFL: lateral PF ligament, MPFL: medial PF
ligament.
 Knee joint in open kinetic chain extension exercises 57

ratio of 0.45. The matrix of menisci (apart from

reinforcing nonlinear collagen fibrils in radial and
circumferential directions) is taken isotropic with
10 MPa for the elastic modulus and 0.45 for the Poisson’s
ratio. Each meniscus matrix is stiffened by a higher
modulus of 15 MPa at both ends (, 5 mm length) where
inserted into the tibia to simulate its horns. Articulations at
the cartilage –cartilage and cartilage – meniscus regions
are represented by a large displacement frictionless hard
contact algorithm with no penetration allowed. Total
ligament initial cross-sectional areas are taken as 42, 60,
18, 25, 99, 42.7 and 28.5 mm2 for the ACL, PCL, LCL,
MCL, PT, MPFL and LPFL, respectively. Additional
details of the model are available elsewhere (Mesfar and Figure 2. Computed quadriceps forces at different flexion angles under
Shirazi-Adl 2005, 2006b). two OKC loading cases of gravity alone (OKC) or gravity with a 30 N
For stable and fully unconstrained boundary conditions resistant force (OKC þ 30 N). The ratios to the leg and foot weight are
also shown (right axis).
in flexion, the femur is fixed while the tibia and the patella
are left completely free. The joint reference configuration
especially so at larger flexion angles reaching the
at full extension is initially established under ligament
maximum of 899 N at 908 flexion (figure 2). The total
prestrains (Mesfar and Shirazi-Adl 2005, 2006b). To
force in the PT at different flexion angles followed the
account for the weight of the leg and the foot, two gravity
same trend as that of quadriceps forces when gravity load
forces of 29.3 and 7.85 N, respectively, are applied at their
alone was considered reaching a relatively small force of
respective mass centres based on anthropometric data for
33 N at 908 flexion (figure 3). In presence of the external
female subjects (De Leva 1996) since our finite element
resistant force, and in contrast to quadriceps forces, PT
model was originally constructed based on a female knee
forces markedly decreased with joint flexion so that at 908
joint (Bendjaballah et al. 1995) (figure 1). For the cases
flexion PT force reached its minimum while quadriceps
simulating extension against a resistant force, an
force attained its maximum. The ratio of the PT force to
additional (flexor) force of 30 N is applied normal to the
the corresponding quadriceps force substantially
tibia at the ankle situated at a lever arm of , 372 mm to the
decreased with knee flexion from 0.92 and 0.99 at full
tibial plateau (De Leva 1996) (figure 1). The joint flexion
extension without and with external resistant force,
angles of 0, 30, 60 et 908 are considered for both loading
respectively, to 0.28 and 0.36 at full flexion.
conditions. To circumvent the likely effect of changes in
The flexor moment at the joint, supported primarily by
the medial-lateral positioning of forgoing gravity and
foregoing PT forces, followed similar trends; it markedly
external forces on results in general and on the TF
increased in presence of the external load at the ankle and
internal –external rotations in particular, the coupled tibial
diminished substantially with flexion angle in both loading
internal –external rotations are fixed under applied gravity
conditions, though more so under gravity alone (figure 4).
and resistant forces. After the application of ligament
The effective lever arm of the joint estimated as the ratio
prestrains and at each joint flexion angle, the model
of the extensor moment to associated PT force was found
iteratively searches for the quadriceps forces that maintain
to be slightly larger under gravity alone at 0 and 608 angles
equilibrium while under the gravity with or without
whereas smaller at 30 and 908 as compared with that in
resistant forces. In this manner, OKC extension exercises
presence of the resistant load. The extensor lever arm,
are simulated at four joint angles and two loading
conditions. The nonlinear analysis is performed using
ABAQUS 6.4 (Hibbit, Karlsson & Sorensen, Inc.,
Pawtucker, RI) finite element package program.

3. Results

For the OKC extension exercise under gravity alone, the

required quadriceps force remained almost constant at 0
and 308, increased only slightly at 608 but then decreased
substantially at 908 flexion (figure 2). The quadriceps
force, expressed as a ratio to the leg/foot weight, reached
its maximum of 6.54 at 608 and its minimum of 3.17 at
908. A reverse trend was found in presence of the 30 N Figure 3. Computed PT forces at different flexion angles under two
OKC loading cases of gravity alone (OKC) or gravity with a 30 N
resistant force in which case the quadriceps force was resistant force (OKC þ 30 N). The ratios to the corresponding
much greater and monotonically increased with flexion quadriceps forces are also shown for both cases (right axis).
58 W. Mesfar and A. Shirazi-Adl
Figure 4. Computed joint moment at different flexion angles under two
OKC loading cases of gravity alone (OKC) or gravity with a 30 N
resistant force (OKC þ 30 N).
however, decreased with joint flexion angle under both
loading conditions, though the reduction was greater
under gravity alone (figure 5).
In association with the tibial anterior translation under
greater quadriceps force at full extension, ACL force
increased more than two-fold when the resistant load was
added at the ankle. This force, however, diminished
thereafter in both loading cases to a small fraction at 308
and further to nil at 608 (figure 6). Despite much greater
quadriceps and PT forces at all flexion angles in the
loading case with the resistant force, ACL force was
greater in presence of the resistant force only at full
extension (figure 6). In contrast to ACL forces, PCL forces
demonstrated a reversed trend with the joint flexion
Figure 5. Computed equivalent lever arm (defined as the ratio of joint
moment over the PT force) at different flexion angles under two OKC
loading cases of gravity alone (OKC) or gravity with a 30 N resistant
force (OKC þ 30 N).
Figure 6. Computed forces in the ACL at different flexion angles under
two OKC loading cases of gravity alone (OKC) or gravity with a 30 N
resistant force (OKC þ 30 N).
Figure 7. Computed forces in the posterior cruciate ligament at
different flexion angles under two OKC loading cases of gravity alone
(OKC) or gravity with a 30N resistant force (OKC þ 30 N).
reaching their maximum at 908 flexion (figure 7). At this
angle, PCL force increased with the resistant load at the
ankle. Relatively small forces (, 50 N) were computed in
collateral ligaments throughout flexion that generally
increased in presence of the resistant force.
Depending primarily on quadriceps and PT forces and
orientations, the total PF contact force increased
dramatically with the load at the ankle, an effect more
evident at larger flexion angles (figure 8). Under gravity
load alone, PF contact force substantially increased up to
608 flexion but then dropped at 908 angle. The increase in
PF contact force was, however, monotonic with joint
flexion when the resistant load was added reaching its
maximum of 896 N at 908 flexion which is noted to be
almost the same as associated quadriceps force. The ratio
of the PF contact force to corresponding quadriceps force
monotonically increased with knee flexion in both loading
cases. The total tibial contact force, on the other hand, was
influenced mainly by PT force and activity in cruciate
ligaments. In contrast to the PF contact force, TF contact
force generally decreased with joint flexion. This force
was much greater in presence of resistant force at all
flexion angles. Under gravity alone, it substantially
diminished with flexion (figure 9). This trend, under
resistant force however, disappeared at larger flexion
Figure 8. Computed resultant PF contact forces at different flexion
angles under two OKC loading cases of gravity alone (OKC)
or gravity with a 30N resistant force (OKC þ 30 N). The ratios to
the corresponding quadriceps forces are also shown for both cases
(right axis).
 Knee joint in open kinetic chain extension exercises
Figure 9. Computed resultant TF contact forces at different flexion
angles under two OKC loading cases of gravity alone (OKC)
or gravity with a 30 N resistant force (OKC þ 30 N). The ratios to
the corresponding quadriceps forces are also shown for both cases
(right axis).
angles. Due to large forces in the PT and the ACL at full
extension, the TF contact force actually exceeded
the applied quadriceps force in both loading cases.
The estimated total PF and TF contact areas followed
similar trends as those described for their respective
contact forces. The PF contact area increased from
, 103 mm2 at full extension to its maximum of 501 mm2
at full flexion under combined loads and from 83 mm2 at
full extension to its maximum of 260 mm2 at 608 flexion
under gravity alone. Under the same loading conditions
respectively, TF contact area decreased from its
maximums of , 840 and 683 mm2 at full extension to
553 and 341 mm2 at full flexion, respectively under
resistant force and gravity alone.
4. Discussion
In this study, the detailed biomechanics of the entire knee
joint was investigated at joint angles of 0, 30, 60 and 908
under OKC extension exercises with and without a 30 N
resistant load at the ankle. For this purpose a validated 3D
nonlinear model of the knee joint was used to compute
quadriceps and PT forces, effective lever arm of the
extensor muscle, joint moment, forces in various joint
ligaments as well as PF and TF contact forces and areas.
Due to the reduction in the lever arm of the gravity
forces with the joint flexion angle, the joint moment
decreased substantially as the flexion increased from
0 to 908; by , nine-fold under gravity alone and by
, two-fold when external load was also added (figure 4).
These joint moments are in close agreement with those
reported for similar OKC exercises (Cohen et al. 2001). It
should be recognized that a negligible portion
(, , 0.4 N m) of these moments could be due to the
passive resistance of the joint itself (Mesfar and Shirazi-
Adl 2005). The PT force followed a similar decreasing
trend though to a lesser extent (figure 3). As a result, the
effective lever arm of the extensor moment (estimated as
59
the ratio of the joint moment over PT force) diminished by
only , 28% under gravity loading alone and by , 18%
under resistant load as the joint flexed from 0 to 908. The
computed extensor lever arms (figure 5) are found to fall
within the range of those reported in the literature
(Tsaopoulos et al. 2006). The forgoing reduction in the
lever arm of the extensor mechanism as the joint flexes,
despite an associated posterior shift in the TF contact
(Dennis et al. 2005, Scarvell et al. 2005) that tends to
increase it, should be due primarily to the considerable
changes in the orientation of PT force with flexion
(Draganich et al. 1987).
In contrast to PT forces, the quadriceps forces
substantially (by , two-fold) increased as joint flexed to
908 in the OKC extension exercise with resistant load and
remained nearly the same throughout flexion except at 908
that markedly dropped to about half of that at 08 when
gravity alone was considered (figure 2). In fact, the
quadriceps forces increased by 90% from 0 to 908 whereas
PT forces diminished by 32% when resistant load was
added while they both decreased by 47 and 63%,
respectively, when the gravity alone was considered.
Such considerable differences in magnitudes and relative
variations during flexion between quadriceps forces and
PT forces confirm that PF joint does not act as a pulley
(Ahmed et al. 1983, 1987). Moreover, observation of the
relative changes in quadriceps forces and joint moment at
different flexion angles (figures 2 and 4) demonstrate that
quadriceps forces lose their extensor moment generating
capacity as joint flexion increases. This corroborates our
earlier findings that quadriceps muscles are much more
efficient at smaller flexion angles in contrast to hamstrings
that are more efficient at larger flexion angles (Mesfar and
Shirazi-Adl 2006a). The computed variations in quad-
riceps forces with joint flexion are in good agreement with
those reported elsewhere (Shelburne and Pandy, 1997,
Cohen et al. 2001) under similar OKC exercises. In
contrast, Grood et al. (1984) measured in OKC exercises,
with and without a weight applied at the ankle, very large
quadriceps forces at full extension whereas very small
forces at 908 flexion. The estimated effective lever arms of
about nil at , 908 flexion reported in this work and in
model studies of Shelburne and Pandy (1997) are also in
clear contradiction to the results of the current study and
those of many others (see the review article of Tsaopoulos
et al. 2006).
Large ACL forces were computed only at full extension
despite quadriceps forces that varied from 473 N at 08 to
899 N at 908 when the OKC extension exercise with
resistant load is considered. At full extension, ACL force
increased from 72 to 151 N as the resistant load was added
at the ankle; an increase directly related to similar
proportional increase in associated quadriceps force. In
our earlier study under constant quadriceps forces,
however, much greater ACL forces (209 N at 08 and
83 N at 308 under 411 N quadriceps force) were computed
that though diminished with flexion angle but remained
nevertheless proportional to magnitude of quadriceps
60 W. Mesfar and A. Shirazi-Adl
forces (Mesfar and Shirazi-Adl 2005). The reason for
these differences is due primarily to the presence of
gravity and resistant forces in the current work that both
act on the knee joint in the posterior direction and hence
reduce ACL forces, especially at smaller flexion angles.
Indeed, the substantial effect of boundary conditions
(i.e. cases with and without similar restraining forces) on
ACL and PCL forces has already been demonstrated in our
earlier studies (Mesfar and Shirazi-Adl, 2006a) in which
ACL forces diminished whereas PCL forces increased as
the knee was restrained by forces rather than moments.
The results, hence, advocate the use of OKC extension
exercises in post-ACL reconstruction periods or in joints
following an ACL injury when performed at joint angles
away from the full extension (. , 208).
In contrast to ACL forces, forces in the PCL were much
smaller and existed essentially only at 908 flexion
(figure 6). Our earlier studies under constant quadriceps
forces indicated that PCL forces, though remaining
relatively small, decreased as quadriceps forces increased
(Mesfar and Shirazi-Adl 2005). In contrast, however,
current results at 908 angle showed a two-fold increase in
PCL force from 19 to 40 N as quadriceps forces increased
from 118 to 899 N in cases without and with resistant force
at the ankle, respectively. Here again similar to previous
discussion on ACL forces, the effect of resisting force at
908 angle that act in the posterior direction is essentially
the primary reason as to why PCL forces increase in
presence of resisting force. Results also demonstrate the
safety of OKC extension exercises following a PCL
reconstruction or in a joint with PCL injury at all flexion
angles in the range of 08 to near 908. At 908 flexion, PCL
forces however are expected to further increase in
presence of greater resistant force.
In OKC extension exercise under gravity load alone, PF
contact force doubled from 0 to 608 and thereafter dropped
back at 908. These variations are in accordance with
similar ones evaluated in quadriceps and PT forces. In
agreement with earlier works (Ahmed et al. 1987,
Shelburne and Pandy 1997), the ratio of the PF contact
force over the applied quadriceps force considerably
increased as joint flexed. In presence of 30 N resistant
force at the ankle, PF contact forces substantially
increased with flexion to reach 896 N at 908 a force level
almost equal to the applied quadriceps force itself. It is
interesting to note that the 30 N resistant force at the ankle
increased PF contact force by 67% at 08 and by 690% at
908 joint angle. It is therefore evident, in agreement with
others (Cohen et al. 2001), that PF contact forces
substantially increase with resistant force especially so at
larger flexion angles. The mean contact stress, calculated
as the ratio of total contact force over the total contact
area, however, remained relatively small (, 1.8 MPa) and
generally unchanged with the joint angle in this case.
Under gravity alone, even smaller contact stresses were
computed that decreased from 1.3 MPa at 08 to 0.5 MPa
at 908. The foregoing computed PF contact forces and
mean contact stresses are in good agreement with those of
Cohen et al. (2001) reported under similar loading
conditions.
In contrast to PF contact forces and areas, TF contact
forces and areas generally decreased with joint flexion
especially for the case with gravity loading alone.
The changes in contact forces with joint flexion are due
primarily to the similar variations in PT force. Mean TF
contact stresses of , 0.35 and 0.65 MPa respectively for
cases without and with resistant load at the ankle remained
nearly constant throughout flexion and were noted to be
much smaller than mean contact stresses at PF joint.
The foregoing PF and TF contact stresses are within the
range of values reported for contact stresses under
different loading conditions (Ahmed et al. 1983,
Bendjaballah et al. 1995, Meyer et al. 1997) and much
smaller than reported ultimate cartilage stress values
(Vener et al. 1992, Flachsmann et al. 2001). The OKC
extension exercises with moderate resistant forces appear
hence safe as far as PF and TF cartilage stresses are
concerned.
Finally, no excessive force or stress in various joint
components was found in the OKC extension exercises
under rather small resistant load level considered in this
study. The magnitude of resistant load used in OKC
extension exercises plays an important role in biomecha-
nics of the joint by substantially increasing the required
quadriceps and PT forces, forces in cruciate ligaments,
and joint contact forces, especially at near 908 joint flexion
angles with the exception of ACL force that is increased at
08 angle. At post-ACL reconstruction period or in the joint
with ACL injury, the exercise should preferably be
avoided under much larger resistant forces and at near full
extension positions.
Acknowledgements
The financial support of the Natural Science and
Engineering Research Council of Canada (NSERC-
Canada) is gratefully acknowledged. The earlier efforts
of M.Z. Bendjaballah and K.E. Moglo in development of
the model are also acknowledged.
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