Eur J Appl Physiol (2000) 83: 71±76
ORIGINAL ARTICLE
Louis R. Osternig á Reed Ferber á John Mercer
Howard Davis
Human hip and knee torque accommodations
to anterior cruciate ligament dysfunction
Accepted: 30 April 2000
Abstract It has been postulated that the adaptations of
lower extremity function exhibited by anterior cruciate
ligament (ACL) de®cient and post-ACL surgical
patients represent early accommodations to the loss of
ACL function after injury so that excessive anterior
displacement of the tibia is prevented. Prior studies have
suggested that compensation patterns in ACL de®cient
and post-ACL surgical subjects may a€ect joint mo-
ments of the knee as well as the hip. However, the
variance in knee and hip forces between ACL de®cient,
post-surgical ACL and uninjured groups has not been
clearly elucidated. The purpose of this study was to as-
sess hip:knee extensor torque ratios relative to anterior
tibia shear in pre-surgical-ACL de®cient, post-surgical
and uninjured subjects. Measurements of hip and knee
joint moments and anterior tibia shear were recorded
from 45 injured and uninjured subjects (21 men,
24 women) during lower extremity, variable resistance
exercise. Anterior tibia shear was computed by decom-
posing joint moments and reaction forces according to a
model derived from cadaver knee dissections and radi-
ography, in combination, to estimate the tibio-femoral
compressive and shear forces generated by the patellar
tendon at various angles throughout the knee joint
range. Three groups of subjects were studied: recently
injured ACL de®cient pre-surgical subjects who were
scheduled for immediate surgery (PRE; n ˆ 15); post-
surgical subjects who had undergone ACL reconstruc-
tive surgery at least 1 year prior to testing (POST;
n ˆ 15); and uninjured controls (CON; n ˆ 15). All PRE
and POST subjects had a normal contralateral limb.
Tests were conducted under six conditions: 1 and 1.5 Hz
cadence and maximal speed at 33% and 50% one rep-
etition maximum resistance. The results revealed that
L. R. Osternig (&) á R. Ferber á J. Mercer á H. Davis
Department of Exercise and Movement Science,
University of Oregon, Eugene, OR 97403, USA
e-mail: louiso@oregon.uoregon.edu
Tel.: +1-541-3463384; Fax: +1-541-3462841
Ó Springer-Verlag 2000
the hip:knee ratios were signi®cantly greater for the
post-ACL surgical group than the PRE and CON
groups (P < 0.01; P < 0.03). There were signi®cant
negative correlations between the hip extensor:knee ex-
tensor torque ratios and maximal anterior tibia shear.
across all groups. The hip:knee extensor torque ratio
increased with decreased anterior tibia shear in all
groups with signi®cant correlations ranging from )0.55
to )0.88 (P < 0.01) for the injured limbs of PRE and
POST groups, and )0.64 to )0.78; (P < 0.01) for the
CON group. The highest overall correlations were found
for the post-surgical subjects. The results revealed that
anterior tibia shear declined signi®cantly with speed
(P < 0.01) in all groups. However, the converse was
true for the hip:knee extensor torque ratio across speeds.
The ratio increased signi®cantly with speed (P < 0.001)
for all groups at the 33% and 50% resistances. The re-
sults suggest (1) that post-ACL surgical subjects appear
to accommodate to ACL substitution by using hip ex-
tensors to a signi®cantly greater extent than the unin-
jured controls in closed-chain lower extremity exercise;
(2) that the hip:knee extensor torque ratio is signi®cantly
related to the magnitude of anterior tibia shear; and (3)
that the anterior tibia shear is signi®cantly reduced as
speed increases in closed-chain lower extremity exercise.
Key words Anterior cruciate ligament á
Muscle accommodation á Closed-chain exercise á
Anterior tibia shear
Introduction
It has been postulated that the adaptations of lower
extremity function exhibited by anterior cruciate liga-
ment (ACL) de®cient and post-ACL surgical patients
represent early accommodations to the loss of ACL
function after injury and subsequent reprogramming of
the locomotor process so that excessive anterior dis-
placement of the tibia is prevented (Berchuck
et al. 1990). It has been speculated that the a€ected
72
extremity may compensate, in part, for this loss through
muscle substitution or altered joint mechanics (Branch
et al. 1985; DeVita et al. 1998; Hurwitz et al. 1997;
Noyes et al. 1983a, 1983b; Snyder-Mackler et al. 1991,
1995).
Prior studies have suggested that compensation pat-
terns in ACL de®cient and post-ACL surgical subjects
may a€ect joint moments of the knee as well as the hip
(Andriacchi et al. 1985; Berchuck et al. 1990; DeVita
et al. 1997). However, the variance in knee and hip
forces between ACL de®cient, post-surgical ACL and
uninjured groups has not been clearly elucidated.
Therefore, the purpose of this study was to assess
hip:knee extensor torque ratios relative to anterior tibia
shear in pre-surgical ACL de®cient, post-surgical, and
uninjured subjects.
Methods
Subjects
Measurements of hip and knee joint moments and anterior tibia
shear were recorded from 45 injured and uninjured subjects
(21 men, 24 women) during lower extremity, variable resistance
exercise. The subjects were grouped according to their injuries as
follows:
1. Recently injured ACL de®cient pre-surgical subjects who were
scheduled for immediate arthroscopic surgery to reconstruct the
ACL with a patellar tendon autograft [PRE; n ˆ 15, mean age
31.97 (SEM 2.81) years, height 174.24 (SEM 2.13) cm, body
mass 76.45 (SEM 3.60) kg]
2. Post-surgical subjects who had undergone ACL reconstructive
surgery with a patellar tendon autograft at least one year prior
to the tests [POST; n ˆ 15, mean age 28.47 (SEM 3.02) years,
height 169.16 (SEM 2.48) cm, body mass 69.90 (SEM 3.29) kg]
3. Uninjured controls [CON; n ˆ 15, mean age 30.07 (SEM 7.79)
years, height 174.92 (SEM 10.92) cm, body mass 72.33 (SEM
14.08) kg]. All PRE and POST subjects had a normal contra-
lateral limb.
The subjects in all groups were ambulatory and physically ac-
tive, although no current, elite, athletes were included in the study.
The post-surgical subjects had participated in various types of
progressive resistance exercise regimens following surgery. How-
ever, no one protocol had been followed by all subjects in this
group. This study was submitted to and approved by the Com-
mittee for the Protection of Human Subjects at the University of
Oregon.
Protocol
All tests were conducted using a closed-chain computer-controlled
dynamometer on which a semirecumbent stepping motion was
performed (Fig. 1). The dynamometer was instrumented to per-
form real time calculations of hip and knee joint moments, using an
inverse dynamics procedure, the model for which has been de-
scribed by Hull and Jorge (1985) and validated by Neptune and
Hull (1995). The test apparatus was equipped with left and right
mechanically independent levers that provided adjustable resis-
tance against which the subjects exerted force with their lower ex-
tremities. External forces and joint position were measured by force
and position transducers located in the crank and at the axis of
rotation of the lever pedals.
To compute the joint moments, subject models were con-
structed prior to the tests. The length, proximal circumference, and
distal circumference of the thigh, leg and foot were measured.
Fig. 1 Test dynamometer
Additional measurements of foot geometry included barefoot and
with shoes height of the estimated center of ankle rotation, the
estimated position of the center of rotation of the hip, and the
position of the foot on the dynamometer pedal. This information
permitted the construction of a subject model and the calculation
of the position of each segment at any instant from instrumented
measurements of crank and pedal angles according to Hull and
Jorge (1985). Data generated from the model included: angular
joint position, angular velocity, angular acceleration, and torque
for the hip and knee and joints throughout the range of motion
tested.
Anterior tibia shear was computed by decomposing joint
moments and reaction forces according to the model by Nisell
(1985) who used cadaver knee dissections and radiography, in
combination, to estimate the tibio-femoral compressive and shear
forces generated by the patellar tendon at various angles
throughout the knee joint range. The knee model used the inter-
polating spline method developed by Skelly and DeVita (1990), and
the measurement of the circumference of leg at the tibial tuberosity
to estimate the moment arm and angle of pull of the patellar ten-
don. The following assumptions were made to partition the
moment and proximal reaction force:
1. All extensor muscle torque at the knee was due to the patellar
tendon.
2. The patellar tendon could only act in tension.
3. The cruciate ligaments acted only in shear.
4. Bone to bone forces acted only in compression.
5. There was no co-contraction.
The shear value generated represented the estimated force loading
the cruciate ligaments. The compressive force represented the es-
timated loading of the tibial plateau in the direction of the long axis
of the segment.
The model did not take into account coactivating hamstring or
gastrocnemius muscle activity. A major problem involved in con-
sidering such antagonist muscles is to quantify their tendon forces.
While it is possible to quantify antagonist muscle activity using
electromyography, it is dicult to quantify tendon force magni-
tudes because the relationship between muscle activity and tendon
force has been shown not always to be linear (Nisell 1985). How-
ever, the model has been shown to correlate well with experimen-
tally measured forces in the ACL and patellar tendon reported by
Paulos et al. (1981), Arms et al. (1984), and Grood et al. (1984).
Procedure
During an initial evaluation session, a one repetition maximum
(1RM) for resisted, combined extension of the hip and knee joints on
the uninvolved limb was measured. This value was used to calculate
the test resistances of 33% and 50% of 1RM for each subject.

Prior to the tests, submaximal warm-up and familiarization
trials were performed at a moderate power on the apparatus.
Following the warm-up, 15 trials were performed for each
of six conditions in which repetitive cycles of the alternating
stepping motion were collected for analysis. The conditions
included three speeds (1 Hz and 1.5 Hz cadences and vol-
untary maximal speed) and two resistances (33% 1RM and
50% 1RM). The 1.0 and 1.5 Hz cadences were selected to
provide two consistent stepping speeds for all subjects in addi-
tion to maximal cadence.
Hip and knee extensor torques were normalized by expressing
these values as the percentage of hip torque relative to corre-
sponding knee torque, or hip:knee ratio, occurring at the time of
peak anterior tibia shear. This permitted comparisons of torque
data across groups and conditions.
Statistical analysis
Analyses of variance (group ´ speed) and Tukey posterior tests
were used to identify signi®cant di€erences (P < 0.05), if any, for:
1. Anterior tibia shear relative to subject group and speed at each
of the two resistances
2. Hip:knee extensor torque ratio relative to subject group and
speed for each of the two resistances
Pearson product-moment correlations were used to calculate
relationships between peak anterior tibia shear and the hip:knee
extensor torque ratio for each subject group.
Results
Mean maximal cadences for each group were: PRE ˆ
2.17 Hz, POST ˆ 2.13 Hz, and CON ˆ 2.36 Hz.
Figure 2 illustrates a representative example from
one subject. Ensemble curves for 15 trials of knee shear,
hip torque and knee torque data for one pre-surgical
subject are presented. The curves run left to right from
the ¯exed to the extended knee positions. Maximal
Fig. 2 Representative example of mean curves of 15 trials of knee
shear, knee and hip torque for one pre-surgical subject. Max Maximal
73
anterior tibia shear during the propulsive phase (top
dotted line) was used as the point within the cycle of
motion at which the hip:knee extensor torque ratio
(bottom two curves) was measured. The knee extensor
torque is greatest at the more ¯exed knee positions while
the hip extensors become dominant at the more ex-
tended positions. The peak anterior tibia shear occurred
at means of 71% (33% 1RM) and 80% (50% 1RM) of
the extension phase of the cycle across all speeds (Ta-
ble 1). This corresponded to mean positions of 33° and
25° of knee ¯exion, respectively.
An analysis of the hip:knee ratio, relative to group,
revealed that these ratios were signi®cantly greater for
the POST-ACL surgical group than the PRE surgical
and CON groups. Figure 3A shows the di€erences be-
tween the groups at the three speeds, for the 33% 1RM
resistance. The POST group had a signi®cantly higher
hip:knee torque ratio at the 1 and 1.5 Hz speeds
(P < 0.03). For the same comparison at the 50% 1RM
resistance, the post-surgical group had a signi®cantly
higher (P < 0.01) hip:knee extensor torque ratio at all
speeds tested (Fig. 3B).
Table 2 shows the Pearson product-moment corre-
lations between the hip extensor:knee extensor torque
ratios and maximal anterior tibia shear. There were
signi®cant negative correlations between these two
variables across all groups. The hip:knee extensor torque
ratio increased with decreased anterior tibia shear in all
groups with signi®cant correlations ranging from )0.55
to )0.88 (P < 0.01) for the injured limbs of PRE and
POST groups, and )0.64 to )0.78 (P < 0.01) for the
CON group. The highest overall correlations were found
for the post-surgical subjects.
Figure 4A shows the change in maximal anterior
tibia shear for the three groups relative to speed at
33% 1RM. The results revealed that anterior shear de-
clined signi®cantly with speed (P < 0.01) in all groups.
A similar ®nding was evident for the larger resistance, of
50% 1RM as seen in Fig. 4B. However, the converse
was true for the hip:knee extensor torque ratio across
speeds. The ratio increased signi®cantly with speed
(P < 0.001) for all groups at the 33% 1RM resistance
(Fig. 5A). A similar phenomenon was evident for the
50% 1RM resistance (Fig. 5B).
Table 1 Values of joint position at which maximal anterior tibia
shear occurred for PRE, POST and CON groups at 33% and 50%
one repetition maximum (1RM). For de®nitions of groups see text
Resistance PRE POST CON
Mean SEM Mean SEM Mean SEM
33% 1RM 72.26a 1.36 70.22 1.78 71.92 1.52
31.48b 0.59 34.45 0.67 32.81 0.69
50% 1RM 81.28a 1.65 79.74 1.50 83.16 2.00
23.76b 0.48 25.26 0.48 21.95 0.53
a
Values in row are percentage of extension cycle
b
Values in row are degrees of knee ¯exion
74

Fig. 3 Hip:knee extensor muscle torque ratio, relative to group for

the three exercise speeds at 33% one repetition maximum (1RM; A)
and 50% 1RM (B). *Signi®cantly greater than the CON group at
corresponding speed (P < 0.03). **Signi®cantly greater than the PRE
and CON groups at corresponding speed (33% 1RM, P < 0.03;
50% 1RM, P < 0.001). Max Maximal velocity, for de®nition of
groups see text

Fig. 4 Maximal anterior tibia shear relative to exercise speed for the
Table 2 Pearson product-moment correlations between hip ex- three groups at 33% one repetition maximum (1RM; A) and
tensor:knee extensor torque ratios and maximum anterior tibia 50% 1RM (B). *Signi®cantly less than 1 and 1.5 Hz speeds in
shear for PRE, POST and CON groups (for de®nitions of groups corresponding group (P < 0.01). Max Maximal velocity, for de®ni-
see text) tion of groups see text
Resistance Speed PRE POST CON
PRE-surgical and CON groups particularly in the faster
33%±1RM 1 Hz )70* )80* )74*
1.5 Hz )62** )81* )78* conditions (Fig. 5A, B). Since the hip and knee extensors
Maximum )88* )87* )64** both contribute to the forces generated at the foot pedal
50%±1RM 1 Hz )66* )78* )75* interface, these data suggest that the POST-ACL surgi-
1.5 Hz )69* )81* )72* cal group favored hip extensor muscles in producing this
Maximum )55** )88* )73*
force to a greater extent than the PRE and CON groups.
*P < 0.01, **P < 0.02 DeVita et al. (1998) have found that 6-month post-sur-
gical ACL subjects used a larger hip extensor muscle
torque than healthy controls during the support phase of
gait. It was suggested that this adaptation may provide
Discussion increased protection for the repaired ACL.
Although the hamstring and gluteal muscles produce
In this study, peak anterior tibia shear occurred at means hip extension, the role of the hamstring, in this regard,
of 33° and 25° of knee ¯exion. These values correspond to may be important due to its in¯uence on the knee.
cadaver data from Hirokawa et al. (1991) who found that Gregor et al. (1985) found signi®cant hamstring electr-
the position of maximal anterior tibia displacement ran- omyogram (EMG) activity (>75% of maximum) was
ged from 15° to 30° of knee ¯exion and depended on the present over a substantial portion of the propulsive
magnitude of hamstring coactivation. phase (hip/knee extensor) of cycling. In a study on the
The POST-ACL surgical group generated signi®- functional roles of the hamstring and quadriceps mus-
cantly higher hip:knee extensor torque ratios than the cles, Andrews (1985) found that the hamstring muscles

Fig. 5 Hip:knee extensor muscle torque ratio relative to exercise
speed for the three groups at 33% one repetition maximum (1RM; A)
and 50% 1RM (B). *Signi®cantly less than 1 and 1.5 Hz speeds in
corresponding group (P < 0.001). Max Maximal velocity, for
de®nition of groups see text
generated a considerable propulsive force during the hip
and knee extension motions of cycling. It was observed
that the hamstring muscles can function to extend the
hip and knee during a sizable portion of the cycle pro-
pulsive phase. In the present study, it is possible that the
hamstrings, as a component of the hip extensor muscles,
became more dominant in the POST-ACL group com-
pared to the PRE and CON groups, thereby increasing
the hip:knee extensor torque ratio, possibly to counter
anterior tibia shear.
In a review on functional adaptations in ACL-de®-
cient knees, Hurwitz et al. (1997) suggested that in-
creased hamstring muscle force could dynamically
substitute for the ACL during stressful activities. An-
driacchi and Birac (1992) showed that ACL de®cient
patients had a higher net hamstring muscle moment
during the early portion of the support phase of various
running activities. Although the post-surgical subjects in
the present study were technically not ACL de®cient,
they did not have a normal ACL and may have
responded similarly to the long-term ACL de®cient
population.
The hamstring muscles are believed to play an im-
portant role in the control of anterior tibia displacement
(Hirokawa et al. 1991; Renstrom et al. 1986; Solomonow
et al. 1987). Osternig et al. (1986, 1995) found that
75
forceful knee extension produced substantial antagonist
hamstring EMG activity throughout the range of motion.
Baratta et al. (1988) suggested that hamstring muscle
coactivation during knee extension assists in joint sta-
bility by exerting an opposing force to anterior tibia
displacement induced by the quadriceps muscles.
Draganich et al. (1989) measured hamstring EMG
during knee extensions from seated and prone positions
and found that the hamstring muscles coactivated with
the quadriceps muscles during the terminal phase of
extension. They suggested that in knee extension exer-
cises, the ACL and hamstring muscles work synergisti-
cally to prevent anterior tibia displacement at this range
of motion. More et al. (1993) used a cadaver to measure
the e€ect of hamstring muscle force on the tension of a
synthetic ACL graft during a simulated squat exercise.
They found that with no hamstring load graft tension
peaked at full knee extension and at 30° of ¯exion. With
a 90 N hamstring load graft tension was signi®cantly
reduced, with the decrease most evident between 15° and
45° of knee ¯exion.
Hirokawa et al. (1991) used a computerized radio-
graph technique to determine the e€ect of hamstring
muscle co-contraction on knee stability in cadavers un-
dergoing simulated quadriceps muscle-induced isometric
knee extension. They reported a signi®cant reduction in
anterior displacement of the tibia with simultaneous low
level loading of the hamstring muscles, in the range of
15°±80° of knee ¯exion. It was noted that reductions in
anterior displacement of the tibia depended on hamstring
muscle load with larger hamstring loads resulting in large
posterior tibia shifts. It was concluded that hamstring
muscle coactivation provides a synergistic action to the
ACL by preventing excessive anterior tibia displacement.
In the present study, peak anterior tibia shear oc-
curred at an average of approximately 30° of knee
¯exion while the hip:knee extensor torque ratio tended
to increase as the knee extended beyond 45° of knee
¯exion (Fig. 2). This increased ratio may serve to at-
tenuate anterior tibia translation, over the more ex-
tended knee joint range (approximately 45°±15° of knee
¯exion), via the hamstring muscles, which have been
shown to be highly active during the generation of hip
extensor torque (Gregor et al. 1985).
Although no pre-injury strength data were available,
it is possible that residual quadriceps muscle weakness
could have contributed to the higher hip:knee ratios
observed in the post-ACL group. However, there were
no signi®cant di€erences between the contralateral
quadriceps muscle torque values of the post-ACL group
suggesting that if a weakness had occurred, it was pre-
sent bilaterally. Consequently, a unilateral weakness
may not explain all of the between-group di€erences for
this measurement.
The correlation analysis revealed that the hip:knee
extensor torque ratio tended to increase with decreases
in anterior tibia shear in all groups (Table 2). The
®nding that the post-surgical group generated the
strongest correlations suggests that ACL dysfunction
76
may result in accommodations that possibly contribute
to reductions in anterior tibia shear (Baratta et al. 1988;
Draganich et al. 1989; Hirokawa et al. 1991; More et al.
1993; Osternig et al. 1986; Solomonow et al. 1987; Ya-
suda and Sasaki 1987a, b).
The ®nding that anterior shear declined signi®cantly
with speed (Fig. 4A, B) suggested that the subjects, re-
gardless of group, tended to reduce the magnitude of
anterior tibia shear as speed increased. In contrast, the
hip:knee extensor torque ratio increased signi®cantly
with speed, for all groups (Fig. 5A, B).
In conclusion, the results of this study suggest that:
1. Post-ACL surgical subjects appear to accommodate
to ACL substitution by using hip extensor muscles to
a signi®cantly greater extent than the uninjured
controls in closed-chain lower extremity exercise.
2. The hip:knee extensor torque ratio is signi®cantly
related to the magnitude of anterior tibia shear.
3. Anterior tibia shear is signi®cantly reduced as speed
increases on closed-chain lower extremity exercise.
Acknowledgements This study was supported in part by a grant
from the National Athletic Trainers Association Research and
Education Foundation.
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