Medial and lateral hamstrings and quadriceps co-activation affects knee joint kinematics and ACL elongation: a pilot study

Excessive tibial translation has been implicated as the cause of serious knee injuries such as anterior cruciate ligament (ACL) injury [1]. Therefore, the focus of many injury prevention and rehabilitation programs is to train co-activation of the hamstrings and quadriceps to constrain this [2, 3]. However, primary evidence supporting the role of hamstring-quadriceps co-activation for constraining tibial translation and subsequent protection of the ACL from injury is limited. This absence of evidence in spite of strong clinical belief in the efficacy of co-activation is likely due to the difficulty of measuring in-vivo tibial translation or ACL elongation while performing a dynamic task.

Tibial translation is typically ‘quantified’ by measuring passive or active knee joint laxity. Passive laxity is the ‘amount’ of passive motion observed in any plane or rotation prior to plateauing of a displacement tension curve [4]. Active laxity is the secondary motion observed in a plane or rotation during active movement which is not associated with the primary movement [4]. For example, some tibial translation may be observed when performing a step-up; the primary movement is knee extension and tibial translation the secondary. Passive knee joint laxity is typically measured in-vivo with anterior draw tests using knee arthrometers or manual tests such as Lachman’s test [1]. However, measures of passive laxity do not reflect functional instability as they are unable to evaluate the effect of muscular control. Active laxity has been implied from in-vitro cadaveric studies [5], however these studies still fail to evaluate the true effect of muscular influences [5]. More recently an in-vivo study which used fluoroscopy and electromyography (EMG) attempted to explain anterior tibial translation (ATT) and the role of hamstring-quadriceps co-activation in an ACL deficient population during both open and closed kinetic chain tasks (seated knee extension and step up respectively) [2]. However, the findings from that study are not conclusive since the EMG and fluoroscopy were not conducted concurrently and ATT was assumed from measuring patella tendon angle [2].

Recent advances in image registration techniques offer the possibility of real-time in-vivo measurement of ATT while executing dynamic tasks whereby computed tomography (CT) images are registered with fluoroscopy (video x-ray) to allow 4-D motion analysis of bone [6‐8]. This methodology provides the opportunity for measuring kinematics with previously unachievable precision while concurrently measuring hamstring and quadriceps activity. Furthermore, by using a biomechanical model to locate the ACL attachments, measurement of the distance between those attachments can provide some insight into ACL length and tension. However, such a procedure is financially costly and requires some ethical consideration due to the radiation dosage administered. Therefore, pilot research using this technique is required to establish its ‘value’.

This pilot study had two primary aims; first, to establish if co-activation of hamstring and quadriceps muscles altered knee joint motion during a step-up task, and secondly to examine if ACL elongation (maximum change in distance between the ACL attachments) was related to co-activation of the hamstring-quadriceps muscles during a step-up. We hypothesized that co-activation of the hamstrings and quadriceps would constrain the knee in terms of rotation and translation and reduce the ACL elongation when performing a step-up.

The step-up with deliberate co-activation resulted in greater activation of the hamstrings, greater co-activation indices for semimembranosus-vastus medialis and biceps femoris-vastus lateralis, and a smaller co-activation index for semimembranosus-biceps (Fig. 3 and Table 1). Furthermore, the period of time between peak activation for each muscle in each co-activation index was smaller (Fig. 3 and Table 2).

Stepping-up with deliberate co-activation consistently resulted in reduced kinematic excursions and decreased elongation of the ACL during the step-up task (Table 3). Analysis of pooled data showed that as the ACL lengthened the knee abducted (r = 0.91; p < 0.001), distracted (r = −0.70; p = 0.02 for relationship between knee joint compression and ACL elongation) and anteriorly translated (r = 0.52; p = 0.01) (Table 4). However, no significant relationship was demonstrated between ACL elongation and internal rotation (r = 0.07; p = 0.85), or for ACL elongation and medial translation (r = 0.44; p = 0.21).

Stronger medial hamstring-quadriceps co-activation, demonstrated by a higher semimembranosus-vastus medialis co-activation index, resulted in a shorter ACL (r = −0.71; p = 0.01) (Fig. 4). With stronger lateral hamstring-quadriceps co-activation, demonstrated by biceps femoris-vastus lateralis co-activation index, the ACL lengthened (r = 0.47; p = 0.05). Finally, the ratio of medial to lateral hamstrings activity decreased as the ACL lengthened (r = −0.23; p = 0.03) meaning that increased medial hamstrings activity was associated with a shorter ACL.

The purpose of this pilot study was to investigate whether hamstring-quadriceps co-activation altered knee joint motion and limited ACL elongation during a step-up task. Although preliminary, the results of this study indicate that increasing co-activation of select hamstring and quadriceps muscles during a step-up task appears to reduce knee joint rotation, abduction, translation and distraction. Not surprisingly therefore, a lesser amount of ACL elongation was observed during the step-up with deliberate co-activation.

Change in ACL length correlated with co-activation of both lateral and medial muscle groups. However, because ACL elongation was positively correlated to the biceps femoris-vastus lateralis co-activation index and inversely correlated to the semimembranosus-vastus medialis co-activation index it is likely that medial hamstring-quadriceps co-activation, not lateral, is associated with smaller ACL elongation. This finding suggests that net co-activation of the hamstrings and quadriceps may reduce ACL elongation provided that the proportion of medial hamstring-quadriceps co-activation exceeds lateral. This hypothesis is supported by our finding that knee abduction, a movement influenced by vastus lateralis and biceps femoris [12‐14], was positively correlated with ACL elongation (Table 4). These findings are meaningful when one considers that current knee reconstruction techniques involve harvesting medial hamstring tendon for ACL grafts.

The study presented in this paper is novel because this is the first time knee joint kinematics and active laxity, in the form of knee joint translations, have been measured in-vivo directly from bone. The methodology has a proven high degree of accuracy [8] and has the advantage of allowing concurrent EMG measurement of muscle activity. Previous studies have lacked accuracy because they have only been able to infer active laxity measurement from measures of patella tendon angle without concurrent measurements of muscle activity [2], or have had to extrapolate from in-vitro experiments [5].

The reductions in ACL length and ATT associated with co-activation are small but the implications are significant. Our research showed that, for a seemingly basic task such as a step-up, ATT and ACL elongation can be reduced by approximately 1.2 mm and 2.0 mm (respectively) with deliberate co-activation of select hamstring-quadriceps muscles. Previous studies have indicated that failure of the ACL is associated with relatively small changes in ACL length; an in-vivo study of passive laxity after ACL injury indicated that left-right 3.0 mm differences in passive laxity on an anterior drawer test is indicative of ACL injury [15]. Cadaveric studies have shown a difference in ATT of approximately 7.0 mm pre and post ACL rupture [16] and primate model research showed the ACL began to fail when stretched by just 5.4 mm and this was exacerbated by the speed at which strain was applied [17]. Good comparisons between animal models and human ACL elongation patterns have been established [18]. Therefore, in view of the small length changes which appear to be required for failure of the ACL, the changes in ACL elongation detected in this study after very simple co-activation training should be considered clinically meaningful in terms of injury prevention and rehabilitation.

The potential for modulation of ACL elongation via neuromuscular training of the medial hamstring muscles is an important implication arising from of this study. There is a possibility that over activity of the lateral hamstrings and quadriceps could put the ACL at risk. This is of particular concern in the patient who has had an ACL repair using a medial hamstring graft given that muscle inhibition can persist for up to 12 months following a muscle strain injury [19]. Increased activity of the lateral hamstrings and quadriceps might ensue following trauma to the medial tendon and could be a contributing factor to the fact that history of ACL injury is a significant risk for ACL injury [1]. This theory is also supported by some opinion which has presented a good argument for prior hamstring injury being a risk factor for ACL injury [14]. However, some caution must be exercised when considering and interpreting these findings because increased co-activation of the medial hamstrings and quadriceps muscle may be associated with osteoarthritis of the knee [20, 21], particularly when one considers that people with prior ACL injury are at increased risk of developing osteoarthritis of the knee later in life [22, 23]. Furthermore, the relationship between the muscles is not necessarily closed, it could be synergistic [24]. Synergism is defined as the distribution of force among individual muscles to produce a given task [24, 25]. The role of each muscle in a given muscle group may be modulated by a synergistic muscle [26], and it is known that the central nervous system considers synergistic muscles as a functional unit as opposed to single motor units [27].

This study has a number of limitations. Firstly the cohort studied was small but as a pilot study the results are promising and, in our view, because of the clinical relevance of hamstring-quadriceps co-activation for ACL injury a larger study is justified despite financial and ethical considerations. Secondly, limitations surrounding EMG data collection were present. For instance, we did not quantify EMG cross-talk when measuring muscle activity. However, methods for measuring cross-talk, such as EMG signal cross-correlation, have been shown to be ineffective in identifying cross-talk [28]. Therefore the likelihood of cross-talk measurement occuring was simply minimized by collecting EMG data according to SENIAM guidelines and applying a double differential signal amplifier which has been shown effective in minimizing cross talk [29]. In addition to this, only peak absolute RMS EMG data was presented; it could be argued that peak RMS EMG normalized to maximum voluntary contraction should be presented as it describes better the magnitude of muscle activation. However, EMG was only used to confirm an increased level of co-activation of selected hamstring and quadriceps muscles for the step-up with deliberate co-activation. Given that the same electrodes were used on the same day on the same participants without removal between step-up conditions, and an increase in activity was seen for each muscle it can confidently be concluded that increased muscle activity was achieved for the step-up with deliberate co-activation. Furthermore, because the difference in timing of peak activation between muscles in each co-activation index reduced for the step-up with deliberate co-activation then we can state with confidence that a higher level of co-activation was achieved and not just increased activation of agonist and antagonist muscles occurring at significantly different time points. A third limitation is related to the statistical analysis for the comparison of means for EMG and kinematic data. We presented only descriptive statistics because the sample size was small. Parametric statistical analysis was not possible because the data did not satisfy the assumptions required for this type of analysis and a non-parametric analysis would likely return a type II error. A greater sample size would allow for statistical analysis for comparisons of means and is necessary to confirm our findings. Finally, timing of peak ACL elongation relative to hamstring-quadriceps co-activation, and muscle activity throughout the gait cycle was not reported. While we can confidently say that the step-up with deliberate co-activation resulted in a higher level of co-activation, we cannot be accurate about when this occurred. Unfortunately, however, it is not possible with currently available technology to synchronize EMG with the image registration technology described in this paper. Assumptions about muscle activation relative to commencement of movement have been well established elsewhere [24, 30‐34] and therefore must be considered.

The results of this pilot study are promising. A future study powered for statistical examination and with some methodological improvements such as requiring participants to complete a more ecologically valid task relevant to ACL injury and enhancing EMG data collection is justified.

This pilot study sought to examine the clinical assumption that hamstring-quadriceps co-activation results in constraining knee from excessive ATT and other kinematic excursions therefore protecting the ACL from elongation. Our preliminary results suggest that medial hamstring-quadriceps co-activation may constrain ACL elongation, however if lateral activation exceeds medial then ACL elongation might ensue. Although the results need confirmation with a larger study, the clinical implications are meaningful in terms of risk assessment and injury prevention.