In vivo load sharing among the quadriceps components

Single-session measures of quadriceps neuromuscular function are reliable in healthy females and unaffected by age

PURPOSE

This study aimed to determine the inter-session reliability of quadriceps neuromuscular function measurements in healthy young and older females.

METHODS

Twenty-six females aged 19-74 years completed two identical experimental sessions on different days. Quadriceps neuromuscular function measurements included isometric maximal voluntary force, high- and low-frequency twitch force, voluntary and evoked (H-reflex, M-wave) electromyography (EMG), and estimated maximal torque, velocity and power derived from torque-velocity relationships. Intra-class correlation coefficients (ICCs), coefficients of variation (CoV) and Bland-Altman plots assessed inter-session reliability. The effect of age on reliability was assessed by linear regression.

RESULTS

Excellent reliability (ICC > 0.8) was shown for all voluntary and evoked mechanical outcomes. Vastus lateralis EMG outcomes showed excellent reliability (ICC > 0.8) with CoVs < 12%, which were better than those of vastus medialis and rectus femoris. Age was not associated with reliability for 27/28 outcomes (P > 0.05).

CONCLUSION

Excellent reliability of voluntary and evoked force and vastus lateralis EMG outcomes measured in healthy females can be attained in one experimental session, irrespective of age. Female neuromuscular function can be accurately assessed across the lifespan with minimal inconvenience, increasing feasibility for future research. The random error should however be considered when quantifying age-related differences in neuromuscular function.

Exploring the Relationship between Ultrasonographic Measures of the Quadriceps and Knee Extensor Muscle Fitness in Endurance-Trained Individuals

Background

B-mode ultrasonography is an accessible and cost-effective method to assess muscle size and quality through muscle thickness (MT) and echo intensity (EI), respectively. Muscle thickness and EI have demonstrated relationships with maximal strength and local muscle endurance, providing a noninvasive and efficient modality to examine muscle fitness. However, these relationships have not been quantified in the individual quadriceps muscles of habitually endurance-trained populations, which may provide information to practitioners regarding rehabilitation and performance.

Methods

Twenty-three participants (males: N = 10; females: N = 13) underwent B-mode ultrasonography to assess MT, EI, and adipose tissue thickness-corrected echo intensity (cEI) in the vastus intermedius (VI), vastus lateralis (VL), and rectus femoris (RF). Muscle fitness was evaluated through maximal strength (1RM) and local muscle endurance (4 sets to failure at 50% 1RM) during dynamic knee extension. Relationships between ultrasonography outcomes and muscle fitness were examined through stepwise multiple linear regression.

Results

The results indicate that VI cEI is the strongest predictor of 1RM strength (r = -0.643), while no ultrasonography-derived measures significantly predicted local muscle endurance.

Conclusion

The study demonstrates that ultrasonography, specifically measures of cEI in the VI, has the greatest association with maximal strength in endurance-trained individuals. These findings suggest monitoring VI muscle size and quality may benefit practitioners who aim to improve knee extension strength for performance or following injury. In addition, the findings support the use of EI examinations in trained populations.

How mechanics of individual muscle-tendon units define knee and ankle joint function in health and cerebral palsy-a narrative review

This study reviews the relationship between muscle-tendon biomechanics and joint function, with a particular focus on how cerebral palsy (CP) affects this relationship. In healthy individuals, muscle size is a critical determinant of strength, with muscle volume, cross-sectional area, and moment arm correlating with knee and ankle joint torque for different isometric/isokinetic contractions. However, in CP, impaired muscle growth contributes to joint pathophysiology even though only a limited number of studies have investigated the impact of deficits in muscle size on pathological joint function. As muscles are the primary factors determining joint torque, in this review two main approaches used for muscle force quantification are discussed. The direct quantification of individual muscle forces from their relevant tendons through intraoperative approaches holds a high potential for characterizing healthy and diseased muscles but poses challenges due to the invasive nature of the technique. On the other hand, musculoskeletal models, using an inverse dynamic approach, can predict muscle forces, but rely on several assumptions and have inherent limitations. Neither technique has become established in routine clinical practice. Nevertheless, identifying the relative contribution of each muscle to the overall joint moment would be key for diagnosis and formulating efficient treatment strategies for patients with CP. This review emphasizes the necessity of implementing the intraoperative approach into general surgical practice, particularly for joint correction operations in diverse patient groups. Obtaining in vivo data directly would enhance musculoskeletal models, providing more accurate force estimations. This integrated approach can improve the clinicians' decision-making process and advance treatment strategies by predicting changes at the muscle and joint levels before interventions, thus, holding the potential to significantly enhance clinical outcomes.

Effect of moxibustion on knee joint stiffness characteristics in recreational athletes pre- and post-fatigue

Objective

Joint stiffness results from the coupling of the nervous system and joint mechanics, and thus stiffness is a comprehensive representation of joint stability. It has been reported that moxibustion can alleviate general weakness and fatigue symptoms and subsequently may influence joint stiffness. This study investigated whether moxibustion could enhance knee joint stiffness in recreational athletes pre- and post-fatigue.

Methods

Eighteen participants were randomized into intervention (5 males: 20.6 ± 1.5 yr; 4 females: 20.8 ± 1.5 yr) and control groups (5 males: 19.4 ± 0.9 yr; 4 females: 20.5 ± 0.6 yr). The intervention group received indirect moxibustion applied to acupoints ST36 (bilateral) and CV4 for 30 min every other day for 4 consecutive weeks. The control group maintained regular exercise without moxibustion. Peak torque (PT) of right knee extensor, relaxed and contracted muscle stiffness (MS) of vastus lateralis, and knee extensor musculoarticular stiffness (MAS) was assessed with an isokinetic dynamometer (IsoMed 2000), myometer, and free oscillation technique, respectively. Measurements were taken at three time points: pre-intervention, post-intervention/pre-fatigue, and post-fatigue.

Results

MAS (P = 0.006) and PT (P = 0.007) in the intervention group increased more from pre-to post-intervention compared with the control group. Post-fatigue MAS (P = 0.016) and PT (P = 0.031) increased more in the intervention group than in the control group.

Conclusion

Moxibustion enhanced PT and knee MAS, suggesting that this intervention could be used in injury prevention and benefit fatigue resistance in young recreational athletes.

Functional outcomes after single quadriceps muscle resection in patients with soft tissue sarcoma of the anterior compartment of the thigh

BACKGROUND

Soft tissue sarcoma (STS) occurs most commonly in the anterior compartment of the thigh. Limb salvage surgery is the mainstay of treatment, however, resections frequently involve muscle sacrifice. This study determines the impact of a single quadriceps muscle sacrifice on daily living functions. This is to assist clinical decision-making relating to when a functional reconstruction should be offered over simple soft tissue coverage for these defects.

METHODS

Patients who underwent single quadriceps resection as part of the management of STS between 2010 and 2020 were selected. Three functional tests were performed: Time Up and Go (TUG), Timed Up and Down Stairs (TUDS) and Toronto Extremity Salvage Score (TESS). The results were compared with age/sex matched healthy reference values and literature cohorts of lower limb STS patients. Correlations between the tests and age and follow-up duration were determined by the Spearman's test.

RESULTS

The mean TESS, TUG and TUDS results of the 13 patients were 89.6%, 9.8 and 1.01 s/step, respectively. These scores were either similar or significantly better than the comparator values. The TESS score showed no statistical significance compared with patients with no muscle resection. TUG and TUDS scores showed significant positive correlation with each other (ρ = 0.885, P = <0.01) and with age (ρ = 0.646, P = 0.017 and ρ = 0.567, P = 0.043, respectively).

CONCLUSION

This is the largest documented case series of single quadriceps resection for STS. The study suggests that this group of patients does not show a functional deficit and therefore does not require functional reconstruction.

Differences in causes of stiff knee gait in knee extensor activity or ankle kinematics: A cross-sectional study

BACKGROUND

Stiff knee gait (SKG), a common occurrence after the onset of stroke, is caused by hyperactivity of the rectus femoris during the swing phase. Another cause of SKG is the weakness of push-off in hemiparetic gait. Prior research did not consider the effect of the magnitude of knee extensors in their subjects.

RESEARCH QUESTION

Does the cause of SKG differ between patients with high and low knee extensor activities during the swing phase?

METHODS

We examined 38 patients with chronic stroke hemiplegia who presented with SKG. After placing an inertia sensor and an electromyogram, patients walked 10 m at a comfortable speed. All patients were categorized per the sign of the principal component 2 (PC2) as a component with large factor loadings of knee extensors attained from the electromyographic amplitude during the early swing phase of the paretic limb. Then, the kinematic parameters of knee flexion and other gait parameters in each group were compared, and a correlation analysis was performed.

RESULTS

In the high PC2 group, the timing of peak knee flexion during the swing phase was early, and vastus lateralis activity during the preswing phase negatively correlated with the knee-flexion angle during the swing phase. In the low PC2 group, the angular velocity of ankle plantar flexion at the toe-off was slow, which positively correlated with the knee-flexion angle during the swing phase.

SIGNIFICANCE

The cause of SKG could be an inappropriate activity of the vastus lateralis rather than the rectus femoris in patients with high knee extensor activity and slow plantar-flexion velocity at toe-off in patients with low knee extensor activity. Not all causes of SKG in patients with hemiplegia are common, and different treatment strategies are needed per the individuality of spastic knee extensor activity.

Elite Rugby Players have Unique Morphological Characteristics of the Hamstrings and Quadriceps Femoris Muscles According to their Playing Positions

Rugby is a popular sport requiring high-intensity and maximal speed actions. Numerous studies have demonstrated that physical performance variables, such as strength, sprinting, and jumping, are different between the forwards and backs. However, there is little information about muscle morphological characteristics specific for each rugby playing position. This study aimed to clarify the morphological characteristics of the thigh muscles in forwards and backs. Ultrasound images were obtained from the proximal, middle, and distal regions of the thigh. Then, the anatomical cross-sectional areas of particular muscles in the hamstrings and quadriceps femoris were calculated for seven forwards, seven backs, and ten non-athletes. The anatomical cross-sectional areas were normalised by the two-third power of lean body mass, and the normalised values of the three regions were averaged as that of the individual muscle. In the hamstrings, the normalised anatomical cross-sectional areas of the biceps femoris long head were significantly greater in forwards than in non-athletes, whereas those of the semitendinosus were significantly greater in backs than in non-athletes. Furthermore, in the quadriceps femoris, the normalised anatomical cross-sectional areas of the rectus femoris and vastus intermedius were significantly greater in forwards than in backs and non-athletes. These results suggest that forwards have great muscularity of the biceps femoris long head and vastus intermedius which can generate large force, whereas backs possess great muscularity of the semitendinosus which can generate high contraction velocity. These findings allow coaches to design more effective training programs according to particular rugby playing positions.

Groove-deepening trochleoplasty reduces lateral patellar maltracking and increases patellofemoral contact pressures: Dynamic simulation

Groove-deepening trochleoplasty is performed to restore patellar stability by increasing the lateral constraint applied to the patella by the trochlear groove. Multibody dynamic simulation of knee function was used to characterize the influence of groove-deepening trochleoplasty on patellar tracking and patellofemoral contact pressures. Computational models were created to represent seven knees with trochlear dysplasia, indicated by a flat trochlear groove and supratrochlear spur. The models were manipulated to remove the spur and deepen the trochlear groove to represent the average shape following a trochleoplasty. Knee squatting was simulated for the preoperative and postoperative conditions. Statistically significant (p < 0.05) differences in output parameters were identified with repeated measures comparisons at every 5° of knee flexion. Trochleoplasty significantly decreased lateral patellar tracking, particularly at low knee flexion angles. Trochleoplasty decreased the peak lateral shift of the patella (bisect offset index) with the knee extended from 0.87 ± 0.14 to 0.75 ± 0.12. Trochleoplasty also significantly decreased the contact area and increased the maximum contact pressure at multiple flexion angles. Trochleoplasty decreased the average contact area by approximately 10% in mid-flexion, with a corresponding increase in the average maximum contact pressure of 13%-23%. Decreased contact area and increased contact pressures are related to altered patellofemoral congruity due to reshaping the femur without a corresponding change to the patella. Clinical significance: The results indicate groove-deepening trochleoplasty decreases lateral patellar maltracking, reducing the risk of patellar dislocations, but can elevate patellofemoral contact pressures, which could contribute to long-term degradation of cartilage.

Dynamics of Quadriceps Muscles during Isometric Contractions: Velocity-Encoded Phase Contrast MRI Study

Objective: To quantify the spatial heterogeneity of displacement during voluntary isometric contraction within and between the different compartments of the quadriceps. Methods: The thigh muscles of seven subjects were imaged on an MRI scanner while performing isometric knee extensions at 40% maximal voluntary contraction. A gated velocity-encoded phase contrast MRI sequence in axial orientations yielded tissue velocity-encoded dynamic images of the four different compartments of the thigh muscles (vastus lateralis (VL), vastus medialis (VM), vastus intermedius (VI), and rectus femoris (RF)) at three longitudinal locations of the proximal–distal length: 17.5% (proximal), 50% (middle), and 77.5% (distal). The displacement, which is the time integration of the measured velocity, was calculated along the three orthogonal axes using a tracking algorithm. Results: The displacement of the muscle tissues was clearly nonuniform within each axial section as well as between the three axial locations. The ensemble average of the magnitude of the total displacement as a synthetic vector of the X, Y, and Z displacements was significantly larger in the VM at the middle location (p < 0.01), and in the VI at the distal location than in the other three muscles. The ensemble average of Z-axis displacement, which was almost aligned with the line of action, was significantly larger in VI than in the other three muscles in all three locations. Displacements of more than 20 mm were observed around the central aponeuroses, such as those between VI and the other surrounding muscles. Conclusions: These results imply that the quadriceps muscles act as one functional unit in normal force generation through the central aponeuroses despite complex behavior in each of the muscles, each of which possesses different physiological characteristics and architectures.

Differences in the mass and quality of the quadriceps with age and sex and their relationships with knee extension strength

BACKGROUND

Although muscle quality evaluations are currently considered important for diagnosing sarcopenia, data from the general population are lacking. This study used mid-thigh computed tomography measurements to evaluate age-related and sex-related differences in quadriceps femoris muscle quality and mass and their relationships with knee extension strength (KES).

METHODS

Cross-sectional data from 520 Japanese individuals (273 men and 247 women, mean age: 63.1 ± 10.6 years) were analysed. Mass and quality were assessed using quadriceps cross-sectional areas (CSAs) and computed tomography values (CTVs), respectively. The four constituent muscles, intermuscular adipose tissue, and entire quadriceps area (total quadriceps muscles + intermuscular adipose tissue) were assessed, and the data were stratified by five age groups and sex. To evaluate age-related decline, linear and quadratic equations were tested for fit according to the constituent muscles and sex. KES could be measured in 472 of the 520 participants (254 men and 218 women, mean age: 62.3 ± 10.3). Multiple linear regression analyses with age-adjusted models were then used for evaluating the relationships between KES and quadriceps measurements.

RESULTS

All muscle CSAs and CTVs showed downward trends with age (men: P < 0.001 for all; women: vastus medialis CTV, P = 0.004; others, P < 0.001); the intermuscular adipose tissue CSA did not show any trend (men: P = 0.938; women: P = 0.139), although its percentage of the entire quadriceps area showed an upward trend in both sexes (P < 0.001). Men exhibited a quadratic decline in the CSAs for the entire quadriceps area (P = 0.016), total quadriceps muscles (P = 0.021), the vastus medialis (P = 0.010) and vastus lateralis (P = 0.038), and all CTVs (rectus femoris, P = 0.044; others, P < 0.001). Women exhibited a quadratic equation in the CTV for rectus femoris (P = 0.031), but a linear decline in the other variables (P < 0.001 for all). Both the total quadriceps muscles CSA and CTV were significantly associated with KES in both sexes (P < 0.001). For each muscle, the CSAs of the vastus medialis (P < 0.001) and vastus intermedius (P = 0.001) were significantly associated with KES in men, whereas the vastus medialis CSA (P < 0.001), vastus lateralis CSA (P = 0.006), rectus femoris CSA (P = 0.020), and vastus intermedius CTV (P = 0.025) were significantly associated with KES in women CONCLUSIONS: Age-related quadriceps femoris changes in mass and quality differed by sex and the constituent muscles. The constituent muscles contributing to KES differed between men and women. Quadriceps CSA and CTV measurements are useful for objectively assessing age-related and sex-related muscle deterioration and KES.

The effect of stretch-shortening magnitude and muscle-tendon unit length on performance enhancement in a stretch-shortening cycle

Stretch-induced residual force enhancement (rFE) is associated with increased performance in a stretch–shortening cycle (SSC). Although the influence of different range of motions and muscle–tendon unit lengths has been investigated in pure stretch-hold experiments in vivo, the contribution to a SSC movement in human muscles remains unclear. In two sessions, 25 healthy participants performed isometric reference (ISO), shortening hold (SHO) and SSC contractions on an isokinetic dynamometer. We measured the net knee-joint torque, rotational mechanical work, knee kinematics and fascicle behavior (m. vastus lateralis) of the upper right leg. In session 1 the SHO- and SSC-magnitude was changed respectively (SHO: 50°–20°, 80°–20° and 110°–20°; SSC: 20°–50°–20°, 20°–80°–20° and 20°–110°–20°) and in session 2 the muscle–tendon unit length (SHO: 50°–20°, 80°–50° and 110°–80°; SSC: 20°–50°–20°, 50°–80°–50° and 80°–110°–80°; straight leg = 0°). In both sessions, rotational work was significantly (p < 0.05) increased in the SSC compared to the SHO contractions (in the range of 8.1–17.9%). No significant difference of joint torque was found in the steady-state for all SSC-magnitudes compared to the corresponding SHO contractions in session 1. In session 2, we found only significantly (p < 0.05) less depressed joint torque in the SSC at the longest muscle–tendon unit length compared to the corresponding SHO condition, without any differences in knee kinematics and fascicle behavior. Therefore, the physiological relevance of rFE might be particularly important for movements at greater muscle–tendon unit lengths.

The Effect of Quadriceps Muscle Length on Maximum Neuromuscular Electrical Stimulation Evoked Contraction, Muscle Architecture, and Tendon-Aponeurosis Stiffness

Muscle-tendon unit length plays a crucial role in quadriceps femoris muscle (QF) physiological adaptation, but the influence of hip and knee angles during QF neuromuscular electrical stimulation (NMES) is poorly investigated. We investigated the effect of muscle length on maximum electrically induced contraction (MEIC) and current efficiency. We secondarily assessed the architecture of all QF constituents and their tendon-aponeurosis complex (TAC) displacement to calculate a stiffness index. This study was a randomized, repeated measure, blinded design with a sample of twenty healthy men aged 24.0 ± 4.6. The MEIC was assessed in four different positions: supine with knee flexion of 60° (SUP60); seated with knee flexion of 60° (SIT60); supine with knee flexion of 20° (SUP20), and seated with knee flexion of 20° (SIT20). The current efficiency (MEIC/maximum tolerated current amplitude) was calculated. Ultrasonography of the QF was performed at rest and during NMES to measure pennation angle (θ_p) and fascicle length (L_f), and the TAC stiffness index. MEIC and current efficiency were greater for SUP60 and SIT60 compared to SUP20 and SIT20. The vastus lateralis and medialis showed lower θ_p and higher L_f at SUP60 and SIT60, while for the rectus femoris, in SUP60 there were lower θ_p and higher L_f than in all positions. The vastus intermedius had a similar pattern to the other vastii, except for lack of difference in θ_p between SIT60 compared to SUP20 and SIT20. The TAC stiffness index was greater for SUP60. We concluded that NMES generate greater torque and current efficiency at 60° of knee flexion, compared to 20°. For these knee angles, lengthening the QF at the hip did not promote significant change. Each QF constituent demonstrated muscle physiology patterns according to hip and/or knee angles, even though a greater L_f and lower θ_p were predominant in SUP60 and SIT60. QF TAC index stiffened in more elongated positions, which probably contributed to enhanced force transmission and slightly higher torque in SUP60. Our findings may help exercise physiologist better understand the impact of hip and knee angles on designing more rational NMES stimulation strategies.

Does Varying Repetition Tempo in a Single-Joint Lower Body Exercise Augment Muscle Size and Strength in Resistance-Trained Men?

Pearson, J, Wadhi, T, Barakat, C, Aube, D, Schoenfeld, BJ, Andersen, JC, Barroso, R, Ugrinowitsch, C, and De Souza, EO. Does varying repetition tempo in a single-joint lower body exercise augment muscle size and strength in resistance-trained men? J Strength Cond Res XX(X): 000-000, 2021-This study compared the effects of FAST and SLOW eccentric repetition tempo in a single exercise volume-matched intervention on muscle thickness (MT) and strength in resistance-trained men. Using a within-subject design, 13 subjects had each leg randomly assigned to SLOW (1-0-3) or FAST (1-0-1) repetition tempo. Subjects underwent an 8-week strength-training (ST) intervention performed twice weekly. Unilateral leg-extension one repetition-maximum (1RM) and anterior thigh MT at the proximal (MTP) and distal (MTD) portions were assessed via ultrasound imaging at baseline and after 8 weeks of RT. Rating of perceived exertion (RPE) assessments of the training sessions (i.e., 16 per leg) were averaged for further analysis. Both legs similarly increased MTP (estimated differences: FAST: 0.24 cm, 3.6%; SLOW: 0.20 cm, 3.1%). However, for MTD, analysis of covariance analysis showed a leg effect (p = 0.02) in which absolute pre-to-post change was greater in FAST compared with SLOW (estimated differences: FAST 0.23 cm, 5.5%; SLOW: 0.13 cm, 2.2%). For 1RM, both legs similarly increased maximum strength (estimated differences: FAST: 9.1 kg, 17.0%; SLOW: 10.4 kg, 22.1%, p <= 0.0001). The SLOW group had a higher RPE than FAST (8.59 vs. 7.98, p = 0.002). Despite differences in RPE, our results indicate that both repetition tempos produced similar muscular adaptations. However, they also suggest that the FAST tempo may provide a small hypertrophic advantage at the distal quadriceps. From a practical standpoint, strength and conditioning professionals may implement a FAST tempo at least in one single-joint exercise during an 8-week training period to enhance regional hypertrophic adaptations in trained individuals.

Function of the Distal Part of the Vastus Medialis Muscle as a Generator of Knee Extension Twitch Torque

The distal part of the vastus medialis (VM) (VM obliquus: VMO) muscle acts as the medial stabilizer of the patella. However, it has been known to facilitate VMO contraction during training of the quadriceps femoris muscle in knee joint rehabilitation. This study aimed to examine the contribution degree of VMO as a knee joint extension torque generator. Sixteen healthy male volunteers participated in this study. Electrical muscle stimulation (EMS) was performed on VMO at 60° knee angle for 20 min to induce muscle fatigue. Knee extension twitch torques (TT) at 90° and 30° knee angle evoked by femoral nerve stimulation were measured before and after EMS. Although each TT at 90° and 30° knee angle significantly decreased after EMS, the decreased TT rate in both joint angles showed no significant difference. Our results show that VMO might contribute to the generation of the knee joint torque at the same level in the range from flexion to extension. Therefore, it was suggested that the facilitating the neural drive for VMO is important during the quadriceps femoris muscle strengthening exercise.

Effects of knee flexor submaximal isometric contraction until exhaustion on semitendinosus and biceps femoris long head shear modulus in healthy individuals

This study examined whether a knee flexor isometric contraction at 20% of maximal voluntary isometric contraction until exhaustion would alter the biceps femoris long head (BFlh) and semitendinosus (ST) active stiffness, assessed using ultrasound-based shear wave elastography. Twelve healthy individuals participated in 2 sessions separated by 7 days. Time to exhaustion was similar in both sessions (day 1: 443.8 ± 192.5 s; day 2: 474.6 ± 131.7 s; p = 0.323). At the start of the fatigue task, the ST showed greater active stiffness than the BFlh (p < 0.001), with no differences between days (p = 0.08). The ST active stiffness then decreased from 40% of the task time to exhaustion (− 2.2 to − 13.3%, p = 0.027) until the end of the task (− 16.1 to − 22.9%, p = 0.012), while no significant changes were noted in the BFlh (p = 0.771). Immediately after the fatigue task, a decrease in active stiffness was observed in the ST (− 11.8 to − 17.8%, p < 0.001), but not in the BFlh (p = 0.551). Results were consistent between the 2 testing sessions (p = 0.07–0.959). The present results indicate that fatigue alters the hamstring active stiffness pattern.

Surface EMG in Clinical Assessment and Neurorehabilitation: Barriers Limiting Its Use

This article addresses the potential clinical value of techniques based on surface electromyography (sEMG) in rehabilitation medicine with specific focus on neurorehabilitation. Applications in exercise and sport pathophysiology, in movement analysis, in ergonomics and occupational medicine, and in a number of related fields are also considered. The contrast between the extensive scientific literature in these fields and the limited clinical applications is discussed. The "barriers" between research findings and their application are very broad, and are longstanding, cultural, educational, and technical. Cultural barriers relate to the general acceptance and use of the concept of objective measurement in a clinical setting and its role in promoting Evidence Based Medicine. Wide differences between countries exist in appropriate training in the use of such quantitative measurements in general, and in electrical measurements in particular. These differences are manifest in training programs, in degrees granted, and in academic/research career opportunities. Educational barriers are related to the background in mathematics and physics for rehabilitation clinicians, leading to insufficient basic concepts of signal interpretation, as well as to the lack of a common language with rehabilitation engineers. Technical barriers are being overcome progressively, but progress is still impacted by the lack of user-friendly equipment, insufficient market demand, gadget-like devices, relatively high equipment price and a pervasive lack of interest by manufacturers. Despite the recommendations provided by the 20-year old EU project on "Surface EMG for Non-Invasive Assessment of Muscles (SENIAM)," real international standards are still missing and there is minimal international pressure for developing and applying such standards. The need for change in training and teaching is increasingly felt in the academic world, but is much less perceived in the health delivery system and clinical environments. The rapid technological progress in the fields of sensor and measurement technology (including sEMG), assistive devices, and robotic rehabilitation, has not been driven by clinical demands. Our assertion is that the most important and urgent interventions concern enhanced education, more effective technology transfer, and increased academic opportunities for physiotherapists, occupational therapists, and kinesiologists.

Bilateral Comparisons of Quadriceps Thickness after Anterior Cruciate Ligament Reconstruction

Background and objectives: Anterior cruciate ligament reconstruction (ACLR) often results in quadricep atrophy. The purpose of this study was to compare the bilateral thickness of each quadricep component before and after ACLR. Materials and Methods: Cross-sectional study design. In 14 patients who underwent ACLR, bilateral quadricep muscle thicknesses were measured using a portable ultrasound device, 1 h before and 48–72 h after ACLR. Two-way analysis of variance (ANOVA) was used to compare muscle thickness pre- and post-ACLR between the limbs. Results: The primary finding was that the vastus intermedius (VI) muscle was significantly smaller in the reconstructed limb after ACLR compared to that in the healthy limb (Reconstructed limb; RCL = Pre-operated (PRE): 19.89 ± 6.91 mm, Post-operated(POST): 16.04 ± 6.13 mm, Healthy limb; HL = PRE: 22.88 ± 6.07, POST: 20.90 ± 5.78 mm, F = 9.325, p = 0.009, η²p = 0.418). Conclusions: The results represent a selective surgical influence on the quadricep muscle thickness. These findings highlight the need of advanced strengthening exercises in order to restore VI thickness after ACLR.

Acute Effects of Open Kinetic Chain Exercise Versus Those of Closed Kinetic Chain Exercise on Quadriceps Muscle Thickness in Healthy Adults

This study aimed to compare immediate changes in the thickness of the rectus femoris (RF), vastus intermedius (VI), vastus lateralis (VL), vastus medialis (VM), and vastus medialis oblique (VMO) muscles after open kinetic chain exercise (OKCE) and closed kinetic chain exercise (CKCE) and identify the effect of both exercise types on each quadricep muscle for early rehabilitation to prevent knee joint injury. Twenty-six healthy participants (13 males and 13 females) were randomly divided into the OKCE (n = 13) and CKCE (n = 13) groups. The thickness of their quadriceps muscles was measured using a portable ultrasonic imaging device before and after exercise in the sequence RF, VI, VL, VM, and VMO. A two-way repeated measures analysis of variance was used to compare the thickness of each component of the quadriceps muscles between the two groups. The thickness of the RF, VL, VM, and VMO muscles increased after OKCE, and the thickness of the VI muscle showed the greatest increase with a medium–large effect size (F = 8.52, p = 0.01, and d = 0.53). The thickness of the VI, VL, VM, and VMO muscles increased after CKCE, and the VMO muscle had the largest effect size (F = 11.71, p = 0.00, and d = 1.02). These results indicate that the thickness of the quadriceps muscles can be selectively improved depending on the type of exercise.

Tibial tuberosity anteriomedialization vs. medial patellofemoral ligament reconstruction for treatment of patellar instability related to malalignment: Computational simulation

BACKGROUND

Medial patellofemoral ligament reconstruction and tibial tuberosity anteromedialization are common treatment options for recurrent lateral patellar instability, although ligament reconstruction is not commonly applied to knees with lateral malalignment.

METHODS

Multibody dynamic simulation was used to assess knee function following tibial tuberosity anteromedialization and medial patellofemoral ligament reconstruction for knees with lateral malalignment. Dual limb squatting was simulated with six models representing knees being treated for patellar instability with an elevated tibial tuberosity to trochlear groove distance. The patellar tendon attachment on the tibia was shifted medially (10 mm) and anteriorly (5 mm) to represent tibial tuberosity anteromedialization. A hamstrings tendon graft was represented for medial patellofemoral ligament reconstruction. Patellar tracking was quantified based on bisect offset index. The patellofemoral contact pressure distribution was quantified using discrete element analysis. Data were analyzed with repeated measures comparisons with post-hoc tests.

FINDINGS

Both procedures significantly reduced bisect offset index, primarily at low flexion angles. The decrease was larger for tibial tuberosity anteromedialization, peaking at 0.18. Tibial tuberosity anteromedialization shifted contact pressures medially, significantly increasing the maximum medial contact pressure at multiple flexion angles, with the maximum pressure increasing up to 1 MPa.

INTERPRETATION

The results indicate tibial tuberosity anteromedialization decreases lateral patellar maltracking more effectively than medial patellofemoral ligament reconstruction, but shifts contact pressure medially. Tibial tuberosity anteromedialization is likely to reduce the risk of post-operative instability compared to medial patellofemoral ligament reconstruction. The medial shift in the pressure distribution should be considered for knees with medial cartilage lesions, however.

Lateral patellar maltracking due to trochlear dysplasia: A computational study

BACKGROUND

The study focuses on the influence of trochlear dysplasia on patellar tracking related to patellar instability.

METHODS

Knee extension against gravity and dual-limb squatting were simulated with seven models representing knees being treated for recurrent instability. Trochlear depth was altered to represent lateral trochlear inclination (LTI) values of 6°, 12° and 24°. Repeated measures analyses compared patellar lateral shift (bisect offset index) across different LTI values. Peak bisect offset index during extension and squatting was correlated with patella alta (Caton-Deschamps index) and maximum lateral position of the tibial tuberosity.

RESULTS

Bisect offset index varied significantly (p < 0.05) between different LTI values at multiple flexion angles throughout simulated knee extension and squatting. Average bisect offset values were 1.02, 0.95, and 0.86 for LTI = 6°, 12°, and 24°, respectively, at 0° of flexion for knee extension. The strongest correlation occurred between peak bisect offset index and lateral position of the tibial tuberosity for knee squatting with LTI = 6° (r² = 0.81, p = 0.006). The strength of the correlation decreased as LTI increased. Caton-Deschamps was only significantly correlated with patellar tracking for LTI = 24° during knee squatting.

CONCLUSIONS

A shallow trochlear groove increases lateral patellar maltracking. A lateral tibial tuberosity in combination with trochlear dysplasia increases lateral patellar tracking and the risk of patellar instability. Patella alta has relatively little influence on patellar tracking in combination with trochlear dysplasia due to the limited articular constraint provided by the trochlear groove.

Positive relationship between passive muscle stiffness and rapid force production

We aimed to examine the relationship among the muscle shear modulus at rest, maximal joint torque, and rate of torque development (RTD). Twenty-seven participants (28 ± 5 years, 13 women) were recruited in the study. The cross-sectional area (CSA) of the medial gastrocnemius (MG) muscle belly and shear modulus at an ankle joint angle of 0° were calculated using magnetic resonance imaging and ultrasound shear wave elastography, respectively. Subsequently, participants performed maximal isometric plantar flexion at 0° ankle joint angle [maximal voluntary contraction (MVC) test] as fast and hard as possible (RTD test). RTD was calculated from the time-torque curve over time intervals of 0-30, 0-50, 0-100, 0-150, and 0-200 ms from the onset of plantar flexion during the RTD test and was normalized by MVC torque to exclude muscle strength. MG CSA correlated significantly with MVC torque (r = 0.572), whereas MG shear modulus did not. In contrast, MG shear modulus correlated significantly with normalized RTD at all time intervals (r = 0.460-0.496). These results suggest that passive muscle stiffness is not associated with muscle force; however, higher passive muscle stiffness at a given joint angle may contribute to rapid force production.

Extra excitation of biceps femoris during neuromuscular electrical stimulation reduces knee medial loading

Medial knee joint osteoarthritis (OA) is a debilitating and prevalent condition. Surgical treatment consists of redistributing the forces from the medial to the lateral compartment through osteotomy, or replacing the joint surfaces. As the mediolateral load distribution is related to the action of the musculature around the knee, the aim of this study was to devise a technique to redistribute these forces non-surgically through changes in muscle excitation. Eight healthy subjects participated in the experiment, and neuromuscular electrical stimulation was used to change the muscle forces around the knee. A musculoskeletal model was used to quantify the loading on the medial compartment of the knee, and a novel algorithm devised and implemented to simulate neuromuscular electrical stimulation. The forces and moments at the knee, ground reaction forces, walking velocity and step length were quantified before and after stimulation. Stimulation of the biceps femoris resulted in a significant decrease in the second peak of the medial knee joint loading by up to 0.17 body weight (p = 0.016). Kinematic parameters were not significantly affected. Neuromuscular electrical stimulation can decrease the peak loads on the medial compartment of the knee, and thus offers a promising therapy for medial knee joint OA.

Identification of knee gait waveform pattern alterations in individuals with patellofemoral pain using fast Fourier transform

Patellofemoral pain (PFP) is one of the most common overuse injuries of the knee. Previous research has found that individuals with PFP exhibit differences in peak hip kinematics; however, differences in peak knee kinematics, where the pain originates, are difficult to elucidate. To better understand the mechanism behind PFP, we sought to characterize differences in knee gait kinematic waveform patterns in individuals with PFP compared to healthy individuals using fast Fourier transform (FFT). Sixteen control and sixteen individuals with PFP participated in a fast walk protocol. FFT was used to decompose the sagittal, frontal and transverse plane knee gait waveforms into sinusoidal signals. A two-way ANOVA and Bonferroni post hoc analysis compared group, limb and interaction effects on sagittal, frontal and transverse amplitude, frequency and phase components between control and PFP individuals gait waveforms. Differences in frequency and phase values were found in the sagittal and frontal plane knee waveforms between the control and PFP groups. The signal-to-noise ratio also reported significant differences between the PFP and control limbs in the sagittal (p<0.01) and frontal planes (p = 0.04). The findings indicate that differences in gait patterns in the individuals with PFP were not the result of amplitude differences, but differences attributed to temporal changes in gait patterns detected by the frequency and phase metrics. These changes suggest that individuals with PFP adopted a more deliberate, stiffer gait and exhibit altered joint coordination. And the FFT technique could serve as a fast, quantifiable tool for clinicians to detect PFP.

Computational simulation of medial versus anteromedial tibial tuberosity transfer for patellar instability

The study utilizes dynamic simulation of knee function to determine how tibial tuberosity medialization and anteromedialization influence patellar tracking and contact pressures for knees with patellar instability. Dual limb squatting was simulated with six multibody dynamic simulation models representing knees being treated for patellar instability. Each knee exhibited lateral patellar maltracking in the pre-operative condition based on the bisect offset index. The patellar tendon attachment points on the tibia were medialized by 10 mm to represent tibial tuberosity medialization, with an additional 5 mm of anteriorization applied for anteromedialization. The patellofemoral contact pressure distribution was quantified using discrete element analysis. Data were analyzed with repeated measures analysis of variance with post-hoc tests and linear regressions. Tibial tuberosity medialization and anteromedialization significantly (p < 0.05) decreased the bisect offset index for nearly all flexion angles up to 80°, with the largest changes near full extension. Both procedures significantly decreased the maximum lateral pressure at 55°, but increased the maximum medial pressure from 30 to 80°. The pre-operative to post-operative increase in the maximum contact pressure was significantly correlated with the maximum pre-operative bisect offset index for tuberosity medialization (r²  = 0.84), but not for anteromedialization. Statement of Clinical Significance: The results indicate tibial tuberosity medialization decreases patellar lateral maltracking and lateral patellofemoral contact pressures, but increases medial contact pressures. When pre-operative patellar maltracking is relatively low, tibial tuberosity medialization is likely to increase maximum contact pressures. Tibial tuberosity anteromedialization lowers the risk of elevated post-operative contact pressures compared to medialization. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3231-3238, 2018.

Biomechanical Methods to Quantify Muscle Effort During Resistance Exercise

Chiu, LZF. Biomechanical methods to quantify muscle effort during resistance exercise. J Strength Cond Res 32(2): 502-513, 2018-Muscle hypertrophy and strength adaptations elicited by resistance training are dependent on the force exerted by active muscles. As an exercise may use many muscles, determining force for individual muscles or muscle groupings is important to understand the relation between an exercise and these adaptations. Muscle effort-the amount of force or a surrogate measure related to the amount of force exerted during a task-can be quantified using biomechanical methods. The purpose of this review was to summarize the biomechanical methods used to estimate muscle effort in movements, particularly resistance training exercises. These approaches include the following: (a) inverse dynamics with rigid body models, (b) forward dynamics and EMG-driven models, (c) normalized EMG, and (d) inverse dynamics with point-mass models. Rigid body models quantify muscle effort as net joint moments. Forward dynamics and EMG-driven models estimate muscle force as well as determine the effect of a muscle's action throughout the body. Nonlinear relations between EMG and muscle force and normalization reference action selection affect the usefulness of EMG as a measure of muscle effort. Point-mass models include kinetics calculated from barbell (or other implement) kinematics recorded using electromechanical transducers or measured using force platforms. Point-mass models only allow the net force exerted on the barbell or lifter-barbell system to be determined, so they cannot be used to estimate muscle effort. Data from studies using rigid body models, normalized EMG, and musculoskeletal modeling should be combined to develop hypotheses regarding muscle effort; these hypotheses should be verified by training interventions.

Dynamic tracking influenced by anatomy following medial patellofemoral ligament reconstruction: Computational simulation

BACKGROUND

Continued patellar instability can occur following medial patellofemoral ligament (MPFL) reconstruction. Computational simulation of function was used to investigate the influence of the lateral position of the tibial tuberosity, trochlear dysplasia and patella alta on lateral patellar tracking following MPFL reconstruction.

METHODS

Multibody dynamic simulation models were developed to represent nine knees being treated for recurrent patellar instability. Knee extension against gravity and dual limb squatting were simulated with and without simulated MPFL reconstruction. Graft resting lengths were set to allow 10mm and five millimeters of patellar lateral translation at 30° of knee flexion. The bisect offset index, lateral tibial tuberosity to posterior cruciate ligament tibial attachment (TT-PCL) distance, lateral trochlear inclination, and Caton-Deschamps index were quantified at every five degrees of knee flexion to characterize lateral tracking, lateral position of the tibial tuberosity, trochlear dysplasia, and patella alta, respectively. For the pre-operative and post-operative conditions and each type of motion, bisect offset index was correlated with the anatomical parameters using stepwise multivariate linear regression.

RESULTS

For both motions, the pre-operative and post-operative bisect offset indices were significantly correlated with lateral trochlear inclination and lateral TT-PCL distance. For both motions, the adjusted r² decreased with MPFL reconstruction, but was still approximately 0.5 for MPFL reconstruction allowing five millimeters of lateral translation.

CONCLUSION

MPFL reconstruction decreases but does not eliminate lateral maltracking related to trochlear dysplasia and a lateralized tibial tuberosity. Patients with these pathologies are likely at the highest risk for instability related to maltracking following MPFL reconstruction.

The effect of rolling massage on the excitability of the corticospinal pathway

The aim of the present study was to investigate the alterations of corticospinal excitability (motor evoked potential, MEP) and inhibition (silent period, SP) following rolling massage of the quadriceps muscles. Transcranial magnetic and femoral nerve electrical stimuli were used to elicit MEPs and compound muscle action potential (Mmax) in the vastus lateralis and vastus medialis muscles prior to and following either (i) 4 sets of 90-s rolling massage (ROLLING) or (ii) rest (CONTROL). One series of neuromuscular evaluations, performed after each set of ROLLING or CONTROL, included 3 MEPs and 1 Mmax elicited every 4 s during 15-s submaximal contractions at 10% (experiment 1, n = 16) and 50% (experiment 2, n = 10) of maximal voluntary knee extensions (MVC). The MEP/Mmax ratio and electromyographic activity recorded from vastus lateralis at 10% MVC demonstrated significantly lower values during ROLLING than CONTROL (P < 0.05). The ROLLING did not elicit any significant changes in muscle excitability (Mmax area) and duration of transcranial magnetic stimulation-induced SP recorded from any muscle or level of contraction (P > 0.05). The findings suggest that rolling massage can modulate the central excitability of the circuitries innervating the knee extensors; however, the observed effects are dependent on the background contraction intensity during which the neuromuscular measurements are recorded.

Localization of damage in the human leg muscles induced by downhill running

We investigated localization of damage within the knee extensors (KEs) and plantar flexors (PFs) induced by downhill running (DR) by using transverse relaxation time (T₂)-weighted magnetic resonance imaging (MRI). Fourteen young adults performed 45-min DR (-15% slope) at their maximal tolerable velocity. At pre- and 24, 48, and 72 h post-exercise, T₂-MRI was scanned and T₂ values for each muscle composing KEs and PFs at proximal, middle, and distal sites were calculated. Maximal isometric torque and rate of torque development (RTD: 0-30, 0-50, 0-100, 0-200 ms) were also measured. Maximal torque significantly decreased in KEs (14-17%) and PFs (6-8%) at 24-48 h post-exercise, with greater reductions for KEs. RTD in all phases, except for 0-200 ms in PFs, significantly decreased in KEs (11-42%) and PFs (13-23%) at least at one time point post-exercise. T₂ significantly increased at several sites (3-5%) in both muscle groups at 24 and/or 48 h post-exercise. Among the T₂-increased sites, the peak effect size (Cohen's d) regarding T₂ change was pronounced at proximal (1.05) and middle (1.64) vastus intermedius compared to the other sites (0.72-0.77). These results suggest that DR induces damage in both KEs and PFs, and especially affects proximal-middle sites of the vastus intermedius.

Sonographic Measurement of the Quadriceps Muscle in Patients With Chronic Obstructive Pulmonary Disease: Functional and Clinical Implications

OBJECTIVES

The purpose of this study was to determine the association between functionality as assessed by the 6-minute walking test (6MWT), maximal voluntary contraction of the quadriceps (MVCQ), and quadriceps thickness and echo intensity as measured by sonography, in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Maximal voluntary contraction of the quadriceps and the thickness and echo intensity of the rectus femoris and vastus intermedius were evaluated in 20 patients with COPD. Functionality was assessed by the 6MWT. Differences between the evaluated muscles were determined by the Student t test. Pearson and Spearman rank correlation coefficients were used to analyze relationships between variables of interest, according to data characteristics. Finally, multivariate regression models were applied.

RESULTS

There was a positive correlation between MVCQ and rectus femoris and vastus intermedius thickness (r = 0.427; P = .030; r = 0.469; P= .018, respectively) and a negative correlation between MVCQ and rectus femoris and vastus intermedius echo intensity (r= -0.500; P= .012; r= -0.482; P= .016). No correlation was found between MVCQ and the 6MWT (r = 0.319; P = .085). Multivariate regression analysis showed that the rectus femoris echo intensity, vastus intermedius echo intensity, and vastus intermedius thickness explained 70% of the variance in the distance walked during the 6MWT.

CONCLUSIONS

These results indicate that, in patients with COPD, both quadriceps force and exercise capacity are associated with quantitative (thickness) and qualitative (echo intensity) characteristics of the quadriceps. Consequently, comprehensive assessments of peripheral muscles should simultaneously include both measurements.

Structural diversity of the vastus intermedius origin revealed by analysis of isolated muscle specimens

The quadriceps femoris (QF), a major extensor of the knee joint, plays an important role in human movement. However, descriptions of the three vastus muscles of the QF in anatomy textbooks remain confusing. We analyzed 33 QFs by a novel approach, using isolated muscle specimens to clarify the structures of the vastus lateralis (VL), vastus medialis (VM), and vastus intermedius (VI) origins. The origins of the VL and VM were quite constant in shape and location, but the VI was much more structurally diverse. In typical cases (23 of 33), the origin of the VI attached muscularly to the anterior and lateral surface of the femoral shaft. It adjoined the origin of the VL at the lateral lip (LL) of the linea aspera to form a common origin. In some cases (10 of 33), the muscle belly and origin of the VI were much smaller than those in the typical cases; the origin of the VI attached only to the anterior surface of the femur and did not contact the LL. In addition, the muscle belly of the VI was narrow and almost corresponded to the width of the femoral shaft. The isolated muscle specimen is a useful tool for analyzing individual muscle structures, which can be difficult to observe by routine dissection. Using this method, it became clear that the VI is more structurally diverse in its origin than the VL and VM. Clin. Anat. 30:98-105, 2017. © 2016 Wiley Periodicals, Inc.

Dynamic Simulation of the Effects of Graft Fixation Errors During Medial Patellofemoral Ligament Reconstruction

Background:

Medial patellofemoral ligament (MPFL) reconstruction is performed to prevent recurrent instability, but errors in femoral fixation can elevate graft tension.

Hypothesis:

Errors related to femoral fixation will overconstrain the patella and increase medial patellofemoral pressures.

Study Design:

Controlled laboratory study.

Methods:

Five knees with patellar instability were represented with computational models. Kinematics during knee extension were characterized from computational reconstruction of motion performed within a dynamic computed tomography (CT) scanner. Multibody dynamic simulation of knee extension, with discrete element analysis used to quantify contact pressures, was performed for the preoperative condition and after MPFL reconstruction. A standard femoral attachment and graft resting length were set for each knee. The resting length was decreased by 2 mm, and the femoral attachment was shifted 5 mm posteriorly. The simulated errors were also combined. Root-mean-square errors were quantified for the comparison of preoperative patellar lateral shift and tilt between computationally reconstructed motion and dynamic simulation. Simulation output was compared between the preoperative and MPFL reconstruction conditions with repeated-measures Friedman tests and Dunnett comparisons against a control, which was the standard MPFL condition, with statistical significance set at P < .05.

Results:

Root-mean-square errors for simulated patellar tilt and shift were 5.8° and 3.3 mm, respectively. Patellar lateral tracking for the preoperative condition was significantly larger near full extension compared with the standard MPFL reconstruction (mean differences of 8 mm and 13° for shift and tilt, respectively, at 0°), and lateral tracking was significantly smaller for a posterior femoral attachment (mean differences of 3 mm and 4° for shift and tilt, respectively, at 0°). The maximum medial pressure was also larger for the short graft with a posterior femoral attachment than for standard MPFL reconstruction, with a significant increase in the mean value of 1.6 MPa at 30°.

Conclusion:

MPFL reconstruction reduces lateral tracking, but nonanatomic femoral fixation and overtensioning the graft overcorrect patellar tracking and increase pressure applied to medial patellar cartilage.

Clinical Relevance:

Errors in femoral fixation and graft tensioning can lead to postoperative loss of flexion and overloading of medial cartilage.

Effects of prolonged vibration to vastus intermedius muscle on force steadiness of knee extensor muscles during isometric force-matching task

Afferent inputs from Ia fibers in muscle spindles are essential for the control of force and prolonged vibration has been applied to muscle-tendon units to manipulate the synaptic input from Ia afferents onto α-motor neurons. The vastus intermedius (VI) reportedly provides the highest contribution to the low-level knee extension torque among the individual synergists of quadriceps femoris (QF). The purpose of the present study was to examine the effect of prolonged vibration to the VI on force steadiness of the QF. Nine healthy men (25.1±4.3years) performed submaximal force-matching task of isometric knee extension for 15s before and after mechanical vibration to the superficial region of VI for 30min. Target forces were 2.5%, 10%, and 30% of maximal voluntary contraction (MVC), and force steadiness was determined by the coefficient of variation (CV) of force. After the prolonged VI vibration, the CV of force at 2.5%MVC was significantly increased, but CVs at 10% and 30%MVCs were not significantly changed. The present study concluded that application of prolonged vibration to the VI increased force fluctuations of the QF during a very low-level force-matching task.

Inhomogeneous Quadriceps Femoris Hypertrophy in Response to Strength and Power Training

INTRODUCTION

Previous studies have reported inhomogeneous changes in quadriceps femoris (QF) cross-sectional area (CSA) in response to strength training. It is assumed that these differential changes in muscle shape influence the muscle's functional capacity during high-force and high-power movements. The purpose of the current study was to compare intermuscular and intramuscular QF adaptations to high-load strength training and fast-speed power training.

METHODS

Thirty-six non-strength-trained men were randomly assigned to four groups and completed 8 wk of parallel-depth heavy squat-lift training (HS-P), parallel-depth jump squat training (JS-P), volitional-depth jump squat training (JS-V), or no training (C). Quadriceps femoris, vastus lateralis (VL), intermedius (VI), medialis (VM), and rectus femoris (RF) CSA were measured in distal-, mid-, and proximal-thigh regions using extended field-of-view ultrasonography and compared using a 3 × 2 mixed-model MANOVA with Bonferroni post hoc tests (P < 0.05).

RESULTS

Parallel-depth heavy squat-lift training and JS-P elicited similar changes in mid-CSA(QF) as well as summed CSA of the QF, VL, VI, and VM. Cross-sectional area of the VL (CSA(VL)) and CSA(VI) increased in both HS-P and JS-P at mid-thigh, but only JS-P significantly increased CSA proximally, and only HS-P significantly increased CSA distally. Cross-sectional area of the VM (CSA(VM)) increased in HS-P and JS-P distally, but only HS-P increased at mid-thigh. No hypertrophy was observed in RF at any location and no significant differences were observed between JS-P and JS-V. Parallel-depth heavy squat-lift training elicited greater proximal hypertrophy in each of the vasti muscles, whereas only JS-P elicited distal VL and VI hypertrophy.

CONCLUSIONS

These observed inhomogeneous changes in CSA may alter the thigh's moment of inertia and moment arms of muscle "compartments," and the influence of elastic component force transmission on the muscular force expression. Such selective hypertrophy is speculated to be biomechanically beneficial to high-force or high-power movements used in training.

Knee extension strength and post-operative functional prediction in quadriceps resection for soft-tissue sarcoma of the thigh

Objectives

Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh.

Methods

A total of 18 patients (14 men, four women) underwent total or partial quadriceps resection for soft-tissue sarcoma of the thigh between 2002 and 2014. The number of resected quadriceps was surveyed, knee extension strength was measured with the Biodex isokinetic dynamometer system (affected side/unaffected side) and relationships between these were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D) score and the Short Form 8 were used to evaluate post-operative function and examine correlations with extension strength. The cutoff value for extension strength to expect good post-operative function was also calculated using a receiver operating characteristic (ROC) curve and Fisher’s exact test.

Results

Extension strength decreased when the number of resected quadriceps increased (p < 0.001), and was associated with lower MSTS score, TESS and EQ-5D (p = 0.004, p = 0.005, p = 0.006, respectively). Based on the functional evaluation scales, the cutoff value of extension strength was 56.2%, the equivalent to muscle strength with resection of up to two muscles.

Conclusion

Good post-operative results can be expected if at least two quadriceps muscles are preserved.

Cite this article: A. Tanaka, Y. Yoshimura, K. Aoki, M. Kito, M. Okamoto, S. Suzuki, T. Momose, H. Kato. Knee extension strength and post-operative functional prediction in quadriceps resection for soft-tissue sarcoma of the thigh. Bone Joint Res 2016;5:232–238. DOI: 10.1302/2046-3758.56.2000631.

A patient-specific model of total knee arthroplasty to estimate patellar strain: A case study

BACKGROUND

Inappropriate patellar cut during total knee arthroplasty can lead to patellar complications due to increased bone strain. In this study, we evaluated patellar bone strain of a patient who had a deeper patellar cut than the recommended.

METHODS

A patient-specific model based on patient preoperative data was created. The model was decoupled into two levels: knee and patella. The knee model predicted kinematics and forces on the patella during squat movement. The patella model used these values to predict bone strain after total knee arthroplasty. Mechanical properties of the patellar bone were identified with micro-finite element modeling testing of cadaveric samples. The model was validated with a robotic knee simulator and postoperative X-rays. For this patient, we compared the deeper patellar cut depth to the recommended one, and evaluated patellar bone volume with octahedral shear strain above 1%.

FINDINGS

Model predictions were consistent with experimental measurements of the robotic knee simulator and postoperative X-rays. Compared to the recommended cut, the deeper cut increased the critical strain bone volume, but by less than 3% of total patellar volume.

INTERPRETATION

We thus conclude that the predicted increase in patellar strain should be within an acceptable range, since this patient had no complaints 8 months after surgery. This validated patient-specific model will later be used to address other questions on groups of patients, to eventually improve surgical planning and outcome of total knee arthroplasty.

Action Direction of Muscle Synergies in Three-Dimensional Force Space

Redundancy in the musculoskeletal system was supposed to be simplified by muscle synergies, which modularly organize muscles. To clarify the underlying mechanisms of motor control using muscle synergies, it is important to examine the spatiotemporal contribution of muscle synergies in the task space. In this study, we quantified the mechanical contribution of muscle synergies as considering spatiotemporal correlation between the activation of muscle synergies and endpoint force fluctuations. Subjects performed isometric force generation in the three-dimensional force space. The muscle-weighting vectors of muscle synergies and their activation traces across different trials were extracted from electromyogram data using decomposing technique. We then estimated mechanical contribution of muscle synergies across each trial based on cross-correlation analysis. The contributing vectors were averaged for all trials, and the averaging was defined as action direction (AD) of muscle synergies. As a result, we extracted approximately five muscle synergies. The ADs of muscle synergies mainly depended on the anatomical functions of their weighting muscles. Furthermore, the AD of each muscle indicated the synchronous activation of muscles, which composed of the same muscle synergy. These results provide the spatiotemporal characteristics of muscle synergies as neural basis.

Neuromuscular Activation of the Vastus Intermedius Muscle during Isometric Hip Flexion

Although activity of the rectus femoris (RF) differs from that of the other synergists in quadriceps femoris muscle group during physical activities in humans, it has been suggested that the activation pattern of the vastus intermedius (VI) is similar to that of the RF. The purpose of present study was to examine activation of the VI during isometric hip flexion. Ten healthy men performed isometric hip flexion contractions at 25%, 50%, 75%, and 100% of maximal voluntary contraction at hip joint angles of 90°, 110° and 130°. Surface electromyography (EMG) was used to record activity of the four quadriceps femoris muscles and EMG signals were root mean square processed and normalized to EMG amplitude during an isometric knee extension with maximal voluntary contraction. The normalized EMG was significantly higher for the VI than for the vastus medialis during hip flexion at 100% of maximal voluntary contraction at hip joint angles of 110° and 130° (P < 0.05). The onset of VI activation was 230–240 ms later than the onset of RF activation during hip flexion at each hip joint angle, which was significantly later than during knee extension at 100% of maximal voluntary contraction (P < 0.05). These results suggest that the VI is activated later than the RF during hip flexion. Activity of the VI during hip flexion might contribute to stabilize the knee joint as an antagonist and might help to smooth knee joint motion, such as in the transition from hip flexion to knee extension during walking, running and pedaling.

Interaction of gender and body composition on rectus femoris morphology as measured with musculoskeletal ultrasound imaging

Background:

Quadriceps function is an important measure in patients recovering postoperatively. Traditionally, strength measures that require high levels of resistance are contraindicated during the early postoperative phase. Thus it may be helpful to evaluate the utilization of other tools, such as ultrasound imaging, that allow for assessment during a position of low resistance.

Hypothesis:

The rectus femoris cross-sectional area (CSA) is affected by sex and body composition in healthy subjects.

Study Design:

Cross-sectional study.

Level of Evidence:

Level 4.

Methods:

Thirty-two healthy subjects (16 women, 16 men), selected from a previously larger study, were chosen for analysis. All subjects underwent a maximal volitional isometric contraction protocol from 0° to 90° of knee motion controlled by an isokinetic dynamometer. In the contracted and resting positions, the rectus femoris CSA was measured at each angle using ultrasound imaging. The contractile index (contracted − resting CSA) was calculated at each position. Subjects were separated into 1 of 4 groups based on sex and fat percentage (low or high). These data were analyzed using mixed-factor analysis of variance (group × angle) for each variable, with a critical α level of 0.05.

Results:

A significant interaction was noted for the CSA of the rectus femoris at rest (P < 0.03) and during contraction (P < 0.02). For both variables, all groups performed similarly, with the exception of women with high body fat percentage. No statistically significant interaction existed for the contractile index; however, a main effect for angle (P < 0.01) was observed.

Conclusion:

Rectus femoris CSA appears to depend on sex as well as the body composition of individuals.

Clinical Relevance:

Traditional subjective assessment measures of quadriceps strength and function have low reliability and functional validity. With the improved feasibility of ultrasound imaging in the clinical setting, quadriceps size may be more accurately measured during the early postoperative stages.

Effect of vastus lateralis fatigue on load sharing between quadriceps femoris muscles during isometric knee extensions

The present study aimed to investigate the effects of selective fatigue (i.e., one muscle of the quadriceps) on load sharing strategies during submaximal knee extensions. Shear wave elastography was used to measure muscle shear elastic modulus, as this is considered to be an index of individual muscle force. Sixteen participants attended two experimental sessions that each involved six 10-s knee extensions at 20% of maximal voluntary contraction (MVC) followed by a sustained submaximal isometric knee extension at 20% of MVC, until task failure (Tlim). Between the 10-s contractions and Tlim, participants were required to rest (5 min) for the control session or underwent 5 min of electromyostimulation (EMS) on vastus lateralis (EMS session). Compared with the control session, vastus lateralis shear elastic modulus values were significantly lower after EMS considering both the start of Tlim (54.6 ± 11.8 vs. 68.4 ± 19.2 kPa; P = 0.011) and the entire Tlim contraction (59.0 ± 14.0 vs. 74.4 ± 20.3 kPa; P = 0.019). However, no significant differences were observed for the other recorded muscles (vastus medialis and rectus femoris; both P = 1), i.e., different patterns of changes were found between participants. In conclusion, this study demonstrates that prefatiguing a single agonist muscle does not lead to a consistent redistribution of load sharing among the quadriceps muscles between individuals. These results suggest that the central nervous system does not use a common principle among individuals to control load sharing when neuromuscular fatigue occurs.

The highest antagonistic coactivation of the vastus intermedius muscle among quadriceps femoris muscles during isometric knee flexion

Although the possibility that the vastus intermedius (VI) muscle contributes to flexion of the knee joint has been suggested previously, the detail of its functional role in knee flexion is not well understood. The purpose of this study was to examine the antagonist coactivation of VI during isometric knee flexion. Thirteen men performed 25-100% of maximal voluntary contraction (MVC) at 90°, 120°, and 150° knee joint angles. Surface electromyography (EMG) of the four individual muscles in the quadriceps femoris (QF) was recorded and normalized by the EMG signals during isometric knee extension at MVC. Cross-talk on VI EMG signal was assessed based on the median frequency response to selective cooling of hamstring muscles. Normalized EMG of the VI was significantly higher than that of the other synergistic QF muscles at each knee joint angle (all P<0.05) with minimum cross-talk from the hamstrings to VI. There were significant correlations between the EMG signal of the hamstrings and VI (r=0.55-0.85, P<0.001). These results suggest that VI acts as a primary antagonistic muscle of QF during knee flexion, and that VI is presumably a main contributor to knee joint stabilization.