Patellofemoral Joint Force and Stress during

the Wall Squat and One-Leg Squat

RAFAEL F. ESCAMILLA', NAIQUAN ZHENG 2 , TORAN D. MACLEOD 3 , W. BRENT EDWARDS 4 ,
6
RODNEY IMAMURA5 , ALAN HRELJAC5 , GLENN S. FLEISIG
, KEVIN E. WILK 7 ,
69
.
ANDREWS
R.
JAMES
and
1118,
MOORMAN
CLAUDE T.
1

Department of Physical Therapy, CaliforniaState University, Sacramento, CA; 2Department of Mechanical Engineeringand
EngineeringScience, The Centerfor Biomedical Engineering, University of North Carolina, Charlotte, NC; 3 Department of
Physical Theraphy, Centerfor Biomedical EngineeringResearch, University of Delaware, Newark, DE; Department of
Kinesiology, Iowa State University, Ames, IA; 5Kinesiology and Health Science Department, California State University,
Sacramento, CA; 6American Sports Medicine Institute, Birmingham, AL; 7 Champion Sports Medicine, Birmingham, AL;
8
Duke Sports Medicine Center, Duke University Medical Center, Durham, NC; and 9Andrews-Paulos Research and
Education Institute, Andrews Institute, Gulf Breeze, FL

ABSTRACT
ESCAMILLA, R. F., N. ZHENG, T. D. MACLEOD, W. BRENT EDWARDS, R. IMAMURA, A. HRELJAC, G. S. FLEISIG, K. E.
WILK, C. T. MOORMAN, and J. R. ANDREWS. Patellofemoral Joint Force and Stress during the Wall Squat and One-Leg Squat.

Med. Sci. Sports Exerc., Vol. 41, No. 4, pp. 879-888, 2009. Purpose: To compare patellofemoral compressive force and stress during
the one-leg squat and two variations of the wall squat. Methods: Eighteen subjects used their 12 repetition maximum (12 RM) weight
while performing the wall squat with the feet closer to the wall (wall squat short), the wall squat with the feet farther away from the wall
(wall squat long), and the one-leg squat. EMG, force platform, and kinematic variables were input into a biomechanical model to
calculate patellofemoral compressive force and stress as a function of knee angle. To asses differences among exercises, a one-factor
repeated-measure ANOVA (P = 0.0025) was used. Results: During the squat ascent, there were significant differences in patellofemoral
force and stress among the three squat exercises at 900 knee angle (P = 0.002), 800 knee angle (P = 0.002). 70' knee angle (P <
0.001), and 600 knee angle (P = 0.001). Patellofemoral force and stress were significantly greater at 90' knee angle in the wall squat
short compared with wall squat long and one-leg squat, significantly greater at 700 and 800 knee angles in the wall squat short and long
compared with the one-leg squat and significantly greater at 600 knee angle in the wall squat long compared with the wall squat short
and one-leg squat. Conclusions: Except at 600 and 900 knee angles, patellofemoral compressive force and stress were similar between
the wall squat short and the wall squat long. Between 600 and 900 knee angles, wall squat exercises generally produced greater
patellofemoral compressive force and stress compared with the one-leg squat. When the goal is to minimize patellofemoral compressive
force and stress, it may be prudent to use a smaller knee angle range between 00 and 500 compared with a larger knee angle range
between 600 and 90'. Key Words: BIOMECHANICS, KINETICS, CLOSED CHAIN EXERCISES, KNEE

and females (9). Although patellofemoral rehabilitation can

be a long and arduous process, the use of appropriate
exercises can improve this process by decreasing rehabilitation time and improving function (4,18,26,40,41).
High patellofemoral joint compressive force (patellofemoral force) can result in PFPS from numerous soft tissues,
such as synovial plicae, infrapatellar fat pad, retinacula,
joint capsule, and patellofemoral ligaments (3). Patellofemoral force can also elevate subchondral bone stress
(patellofemoral force per unit patella contact area) in the
patellofemoral joint (2). Because the subchondral bone plate
is rich in pain receptors (42), increased subchondral bone
stress from high patellofemoral force may also result in
PFPS (3). Patellofemoral joint stress can result in a cartilage
degeneration and a decrease in the ability of the cartilage to
distribute patellofemoral force (2). Therefore, understanding
what patellofemoral force and stress magnitudes are generated among patellofemoral rehabilitation exercises may be
helpful to clinicians when prescribing therapeutic exercises
to individuals with PFPS.

In

(PFPS) is the most common type of knee pain and

the outpatient
settingofpatellofemoral
pain- syndrome.
accounts
for 25-30%
all knee pathologies
treated
(10,11,16). Because the etiology of PFPS is poorly understood and multifaceted, it remains one of the most difficult
clinical challenges in rehabilitative medicine (39). PFPS
primarily affects younger active individuals approximately
18-40 yr old (although older individuals can also be
affected), athletes and nonathletes (11,16,21), and males

Address for correspondence: Rafael F. Escamilla, Ph.D., P.T., C.S.C.S.,

F.A.C.S.M., Professor, Department of Physical Therapy, California State

University, 6000 J Street, Sacramento, CA 95819-6020; E-mail: rescamil@

csus.edu.
Submitted for publication July 2007.
Accepted for publication September 2008.
0195-9131/09/4104-0879/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2009 by the American College of Sports Medicine

DOI: 10.1249/MSS.0b0I3e31818e7ead

879

Weight-bearing exercises, such as the squat, are frequently

used during patellofemoral rehabilitation and are specific
to many functional activities such as walking, running,
and jumping (4,18,26,40,41). The use of weight-bearing
exercises have been shown to be effective, both in short- and
long-term outcomes, in decreasing PFPS and in enhancing
functional performance (4,18,26,40,41). Therapists use
these types of exercises to minimize PFPS and muscle loss,
to strengthen hip and thigh musculature, to enhance balance
and stability, and to minimize the risk of future injuries and
associated costs of health care (35). However, all weightbearing exercises may not produce similar magnitudes of
patellofemoral force and stress. Moreover, using varying
techniques within a weight-bearing exercise may also affect
patellofemoral force and stress.
Wall squats and one-leg squats are common weightbearing exercises used by athletes and other individuals
with healthy knees to train the hip and the thigh
musculature. Therapists and trainers also use wall squats,
one-leg squats, and other similar weight-bearing exercises
during patellofemoral rehabilitation for PFPS patients to
allow patients to recover faster and return to function earlier
(4,18,26,40,41). Wall squats can be performed with varying
techniques, such as positioning the heels farther from or
closer to the wall. Positioning the heels farther from the wall
typically results in the knees being maintained over the feet at
the lowest position of the squat, while positioning the heels
closer to the wall typically results in anterior knee translation
beyond the toes at the lowest posidion of the squat.
Performing a one-leg squat also causes the stance knee to
translate forward beyond the toes at the lowest position of the
squat. Clinicians and trainers often believe that anterior
translation of the lead knee beyond the toes during squatting
type exercises increases patellofemoral force and stress, but
there is currently no evidence to support this belief.
Understanding how patellofemoral force and stress vary
among weight-bearing exercises will allow clinicians and
trainers to prescribe safer and more effective knee rehabilitation treatment to patients with PFPS or to athletes during
training. For example, if performingthe wall squat with the
heels closer to the wall (causing greater anterior translation of
the lead knee over the toes) results in greater patellofemoral
force and stress compared with performing the wall squat
with the heels farther away from the wall (causing the lead
knee to be maintained over the foot), a wall squat with the
heels closer to the wall may be-discouraged during training
and rehabilitation. There may also be differences in patellofemoral force and stress over a specific knee flexion range of
motion between wall squat and one-leg squat exercises.
Excess patellofemoral force and stress over time may lead to
PFPS in individuals with asymptomatic patellofemoral joints
or may exacerbate PFPS in patients with patellofemoral
pathology and retard the rehabilitation process.
Currently, patellofemoral force and stress magnitudes
during the wall squat or one-leg squat are unknown.
Therefore, the purpose of this study was to compare

880

Official Journal of the American College of Sports Medicine

patellofemoral force and stress during the wall squat with

the feet farther away from the wall (wall squat long), the
wall squat with the feet closer to the wall (wall squat short),
and the one-leg squat. It was hypothesized that patellofemoral force and stress would be greater in the one-leg squat
compared with the wall squat long, similar between the one.leg squat and the wall squat short and greater in the wall
squat short compared with the wall squat long.
METHODS
Subjects
Eighteen healthy individuals (nine males and nine
females) without a history of. patellofemoral pathology
participated, with an average age, mass, and height of
29 + 7 yr, 77 + 9 kg, and 177 6 cm, respectively, for males
and 25 2 yr, 60 + 4 kg, and 164 + 6 cm, respectively, for
females. All subjects were required to perform the wall squat
and the one-leg squat exercises pain-free and with proper
form and technique for 12 consecutive repetitions'using their
12 repetition maximum (12 RM) weight.
To control the EMG signal quality, the current study was
limited to males and females that had average or below
average body fat, which was assessed by Baseline skinfold
calipers (Model 68900; Country Technology, Inc., Gays
Mill, WI), and appropriate regression equations and body fat
standards set by the American College of Sports Medicine.
Average body fat was 12% 4% for males and 18% 1% for
females. All subjects provided written informed consent in
accordance with the Institutional Review Board at California
State University, Sacramento, which approved the research
conducted and informed consent form.
Exercise Description
Wall squat (Fig. 1A and B). The wall squat began
with the right foot on an AMTI force platform (Model

FIGURE 1-Wall quat with feet farther from wall (wall squat long;
A); wall squat with feet closer to wall (wall squat short; B).

http://www.acsm-msse.org

OR6-6-2000; Advanced Mechanical Technologies, Inc.) and

their left foot on the ground, both knees fully extended (0'
knee angle), the back flat against the wall, and a dumbbell
weight held in both hands with the arms straight and at the
subject's side. From this position, the subject slowly flexed
both knees and squatted down until the thighs were approximately parallel with the ground (resulting in approximately 90-1000 of knee flexion in the wall squat long and
approximately 100-1 100 of knee flexion in the wall squat
short), and in a continuous motion, the subject returned back
to the starting position. A metronome was used to help
ensure that the knees flexed and extended at approximately
45's-I. The surface of the wall was smooth, and a towel

was positioned between the wall and the subject to minimize friction as the subject slid down and up the wall. The
stance width (distance between inside heels) was 32 6 cm
for males and 28 + 7 cm for females, and the foot angle was
approximately 0' (feet pointing approximately straight
ahead), and both stance and foot angle were according to
subject preference.
The wall squat was performed with two technique
variations, wall squat long (Fig. IA) and wall squat short
(Fig. IB). The foot position relative to the wall for the wall
squat long was determined using a heel-to-wall distance that
resulted in the legs being approximately vertical at the
lowest position of the squat (Fig. IA), with the knees above
the ankles, which is commonly recommended by clinicians
and trainers. The average heel-to-wall distance for the wall
squat long was 45 3 cm for males and 41 + 3 cm for
females. The heel-to-wall distance for the wall squat short
was one half the distance of the heel-to-wall distance for the
wall squat long. This distance was chosen because the
shorter heel-to-wall distance for the wall squat short
resulted in the anterior surface of the knee translating
beyond the distal end of the toes at the lowest position of
the wall squat short (Fig. 1B), which is typically discouraged by clinicians and trainers.
One-leg squat. The one-leg squat started with the
subject standing on one leg with the right foot on the AMTI
force platform, the right knee fully extended, the left knee
bent approximately 90', and a single dumbbell weight held
with both hands in front of the chest (subject preference).
From this position, the subject slowly flexed the right knee and
squatted down until the right thigh was approximately parallel
with the ground (resulting in approximately 100-110' of knee
flexion) with the trunk tilted forward approximately 30-40'
(Fig. 2). In a continuous motion, the subject returned back to
the starting position. A metronome was used to help ensure
that the right knee flexed and extended at approximately
45's-1. Like the wall squat short, at the lowest position of

the one-leg squat, the distal surface of the knee translated

beyond the distal end of the toes (Fig. 2).
Data Collection
Each subject came in for a pretest I wk before the testing
session. The experimental protocol was reviewed, the

WALL SQUAT AND ONE-LEG SQUAT

FIGURE 2-One-leg squat.

subject was given the opportunity to practice the one-leg

squat and wall squat exercises, and each subject's heel-towall distances for the wall squat short and long were
determined. In addition, to normalize intensity between the
wall squat and the one-leg squat exercises, each subject's 12
RM was determined. To determine the weight used for the
wall squat short and long, each subject used their 12 RM
weight while performing the wall squat using a heel-to-wall
distance that was halfway between the heel-to-wall distances for the wall squat short and wall squat long, and this
weight was used for the wall squat short and wall squat long
during the testing session. The mean total dumbbell mass
used was 56 + 9 kg for males and 36 + 8 kg for females for
the wall squat short and wall squat long and 15 3 kg for
males and 10 + 3 kg for females for the one-leg squat.
Blue Sensor (Ambu Inc., Linthicum, MD) disposable
surface electrodes (type M-00-S) were used to collect EMG
data. These oval-shaped electrodes (22 mm wide and 30
mm long) were placed in a bipolar electrode configuration
along the longitudinal axis of each muscle, with a center-tocenter distance of approximately 3 cm between electrodes.
Before positioning the electrodes over each muscle, the skin
was prepared by shaving, abrading, and cleaning with
isopropyl alcohol wipes to reduce skin impedance. As
previously described (1), electrode pairs were then placed
on the subject's right side for the following muscles: a)
rectus femoris; b) vastus lateralis; c) vastus medialis; d)
medial hamstrings (semimembranosus and semitendinosus);
e) lateral hamstrings (biceps femoris); and f) gastrocnemius
(midpoint between medial and lateral heads).
Spheres (3.8 cm in diameter) covered with 3MrM reflective tape were attached to adhesives and positioned over
the following bony landmarks: a) third metatarsal head of the
right foot ; b) medial and lateral malleoli of the fight leg; c)
upper edges of the medial and lateral tibial plateaus of the

Medicine & Science in Sports & Exercise 881

right knee; d) posterosuperior greater trochanters of the

left and right femurs; and e) lateral acromion of the right
shoulder.
Once the electrodes and the spheres were positioned, the
subject warmed up and practiced the exercises as needed, and
data collection commenced. A six-camera Peak Performance
motion analysis system (Vicon-Peak Performance Technologies, Inc., Englewood, CO) was used to collect 60-Hz video
data. Force data were collected at 960 Hz using an AMTI
force platform (Model OR6-6-2000, Advanced Mechanical
Technologies, Inc.). EMG data were collected at 960 Hz
using a Noraxon Myosystem unit (Noraxon USA, Inc.,
Scottsdale, AZ). The EMG amplifier bandwidth frequency
was 10-500 Hz, with an input impedance of 20,000 kfl,
and the common-mode rejection ratio was 130 dB. Video,
EMG, and force data were electronically synchronized and
collected as each subject performed in a randomized
manner one set of three continuous repetitions (trials)
during the wall squat short, wall squat long, and one-leg
squat.
Subsequent to completing all exercise trials, EMG data
were collected during maximum voluntary isometric contractions (MVIC) to normalize the EMG data collected
during each exercise (14). The MVIC for the rectus femoris,
vastus lateralis, and vastus medialis were collected in a
seated position at 900 knee and hip flexion with a maximum
effort knee extension (14). The MVIC for the lateral and the
medial hamstrings were collected in a seated position at 90'
knee and hip flexion with a maximum effort knee flexion
(14). MVIC for the gastrocnemius was collected during a
maximum effort standing one-leg toe raise with the ankle
positioned approximately halfway between neutral and full
plantar flexion (14). Two 5-s trials were randomly collected
for each MVIC.

for the three repetitions (trials) were then averaged at

corresponding. knee angles between 00 and 90' and were
used in the biomechanical model described below.
Biomechanical Model
As previously described (14,44), a biomechanical model
of the knee was used to continuously calculate patellofemoral forces throughout a 900 knee range of motion during
the knee flexing (descent) phase (0-90') and knee extending (ascent) phase (90-0') of the wall squat and one-leg
squat (Fig. 3). Resultant force and torque equilibrium
equations were calculated using inverse dynamics and the
biomechanical knee model (14,44). Moment arms for
muscle forces lines of action angles for muscles were
represented as polynomial functions of the knee flexion
angle using data from Herzog and Read (19).
Quadriceps, hamstrings, and gastrocnemius muscle forces
were calculated as previously described (14,44). Because
the accuracy of calculating muscle forces depends on
accurate calculations of. a muscle's physiological crosssectional area (PCSA), a maximum voluntary contraction
force per unit PCSA, and the EMG-force relationship,
resultant force and torque equilibrium equations may not be
satisfied. Therefore, each muscle force F,,(i) was modified
by the following equation:
F.o(i) = cik1 kviAio-.i[EMGi/MVICi],

where Ai was the PCSA of the ith muscle, om(i) was the
MVIC force per unit PCSA of the ith muscle, EMGi
and MVICQ were the EMG window averages of the ith
muscle EMG during exercise and MVIC trials, ci was a
weight factor (values given below) adjusted in a computer

Data Reduction
Video images for each reflective marker were tracked and
digitized in three-dimensional space with Peak Performance
software, using the direct linear transformation calibration
method (31). Testing of the accuracy of the calibration
system resulted in reflective balls that could be located in
three dimensional space with an error less than 4-7 mm.
The raw position data were smoothed with a double-pass
fourth-order Butterworth low-pass filter with a cutoff
frequency of 6 Hz (14). Joint angles, linear and angular
velocities, and linear and angular accelerations were
calculated in a two-dimensional sagittal plane of the knee
using appropriate kinematic equations (14).
Raw EMG signals were full-waved rectified, smoothed
with a 10-ms moving average window, and linear enveloped throughout the knee range of motion for each
repetition. These EMG data were then normalized for each
muscle and expressed as a percentage of each subject's
highest corresponding MVIC trial. The MVIC trials were
calculated using the highest EMG signal over a 1-s time
interval throughout the 5-s MVIC. Normalized EMG data

882

Official Journal of the American College of Sports Medicine

FIGURE 3-Computer optimization with input from measured knee

torque from inverse dynamics and predicted knee torque from muscle
model, where TK = resultant knee torque, FK resultant knee force,
I = moment of inertia about leg center of mass, a = angular acceleration
of leg, m = mass of leg, a = linear acceleration of leg, g = gravitation
constant 9.80 m.s-2, F,.t = external force acting on foot, Text = external
torque acting on foot, FQ = quadriceps force, Fp = patellar tendon
force, FPF = patellofemoral compressive force, FH = hamstrings force,
and FG = gastrocnemius force. Note: to simplify the drawing, the equal
and opposite forces and torques acting on the distal leg and proximal
ankle are not shown.

hfttp://www.acsm-msse.org

optimization program to minimize the difference between

the resultant torque from the inverse dynamics (T,,) and
the resultant torque calculation from the biomechanical
model (Tmi), k1i represented each muscle's force-length
relationship as function of hip and knee angles (based on
muscle length, fiber length, sarcomere length, pennation
angle, and cross-sectional area) (37), and k,,i represented
each muscle's force-velocity relationship based on a Hilltype model for eccentric and concentric muscle actions
using the following equations from Zajac (43) and Epstein
and Herzog (13):
k,, (b- (a/Fo)v)/(b + v) concentric
k, = C- (C -1)(b+
(a/Fo)v)/(b - v)

eccentric

with F0 representing isometric muscle force, v = velocity,

a = 0.32Fo, b = 3.20 s-1, and C = 1.8. Muscle force from
eccentric contractions was scaled up by 1.8 times the
isometric muscle force Fo. Forces generated by the knee
flexors and extensors at MVIC were assumed to be linearly
proportional to their PCSA. Muscle force per unit PCSA at
2
MVIC was 35 N.cm- for the knee flexors and 40 N.cm-2
for the quadriceps (6,24,25,38).
The objective function used to determine each ith
muscle's coefficient ci was as follows:
min f(ci) = I(I

cj) 2 +k (Tre, - ' T,)',

subject to Clow < C _<Chi,h, where clo, and Chigh were lower
and upper limits for ci, and A was -a constant. The weight
factor c was to adjust the final muscle force calculation. The
bounds on c were set between 0.5 and 1.5. The torques
predicted by the EMG-driven model matched well (<2%)
with the torques generated from the inverse dynamics. The
assumptions associated with this model are 1) that the torque
from cruciate ligament forces was ignored and 2) that other
forces and torques out of the sagittal plane were ignored.
Patellofemoral force was a function of patellar tendon
force and quadriceps tendon force. Patellar tendon force was
calculated by the quadriceps tendon force and the ratio of the
patellar tendon force and the quadriceps tendon force, as
previously described (33,34). The angles between the
patellar tendon, quadriceps tendon, and patellofemoral joint
were expressed as functions of knee angle (33,34).
Patellofemoral stress, which was calculated every 10'
between 0' and 900 knee angles, was expressed as the ratio of
patellofemoral force, calculated from the biomechanical
model described above (14,44), and the patellar contact
area. Patellar contact areas were determined at 100 intervals
between 00 and 90' knee angles. Contact areas from in vivo
MRI data from Salsich et al. (30), who also used both male
and female subjects with healthy knees and had them
perform weight-bearing exercise using resistance, were used
at 00 (146 mm 2), 200 (184 mm 2), 400 (290 nIM2), and 60'
(347 mm?) knee angles. These four contact area values

WALL SQUAT AND ONE-LEG SQUAT

formed a near linear relationship as a function of knee angle,

resulting in a line of best fit equation of y = 3.55x + 135
(r = 0.98), with y = contact area and x = knee angle. This

line of best fit equation was used to determine contact areas

at 100 knee angle (171 mm 2), 300 knee angle (242 mm 2),
and 50' knee angle (313 mm 2). The contact areas above at
40', 500, and 600 knee angles were used to develop the line
of best fit equation, y = 2.8 lx + 176 (r = 0.99), which was
used to determine contact areas at 70' knee angle
(373 mm 2), 800 knee angle (401 mm 2), and 900 knee angle
(429 mm 2). Like the current study, a near linear relationship
between patellar contact area and knee angles has been
reported between 0' and 900 knee angles in several studies
involving weight-bearing exercises (2,8,20,27,30).
Data Analysis
To determine significant differences among the wall
squat long, wall squat short, and one-leg squat, patellofemoral force and stress were analyzed every 100 during the
0-900 descent phase and the 90-00 ascent phase using a
one-factor repeated-measure ANOVA. Bonferroni t-tests
were used to assess pairwise comparisons. To minimize the
probability of type I errors secondary to the use of a
separate ANOVA for each knee angle, a Bonferroni
adjustment was performed with the level of significance
established at 0.0025 (0.05/20 knee angles). A separate set
of analyses was not performed for patellofemoral joint
stress values because stress values for each knee angle were
derived from dividing force data by a constant, therefore not
affecting statistical results.

RESULTS
Descriptive patellofemoral force and stress data during
the wall squat and the one-leg squat are shown in Figures 4
and 5. Visual observation of the data indicates that
patellofemoral force and stress progressively increased
during the squat descent and progressively decreased during
the squat ascent, except between 900 and 700 during the
squat ascent in which patellofemoral force and stress
progressively increased. During the squat descent, there
were no significant differences in patellofemoral force and
stress among the three squat exercises. During the squat
ascent, there were significant differences in patellofemoral
force and stress among the three squat exercises at 900 knee
angle (P = 0.002), 80' knee angle (P = 0.002), 700 knee
angle (P < 0.001), and 600 knee angle (P = 0.001).

Patellofemoral force and stress were significantly greater at

900 knee angle in the wall squat short compared with wall
squat long and one-leg squat, significantly greater at 700
and 800 knee angles in the wall squat short and long
compared with the one-leg squat, and significantly greater
at 600 knee angle in the wall squat long compared with the
wall squat short and one-leg squat. At the lowest position of
the wall squat short, the knees translated beyond the toes

Medicine & Science in Sports & Exercise

883

4000

S3000
2000

S1000
0

20

40

60

80

100

80

60

Descent

4(

Ascent
Knee Flexion Angle (deg)

Squat Short
Wall Squat Long
One Leg Squat

FIGURE 4-Mean (SD) patellofemoral joint compressive force for one-leg squat and wall squat exercises.

9 + 2 cm, whereas at the lowest position of the one-leg

squat the knee translated beyond the toes 10 + 2 cm.

DISCUSSION
As hypothesized, patellofemoral force and stress were
greater during the wall squat short compared with the wall
squat long, but only at 90' knee angle during the squat
ascent. At 90' knee angle, the knees translated beyond the
toes in the wall squat short, but the knees remained over the
feet in the wall squat long. Also, as the knees translated
forward beyond the toes in the wall squat short, the
orientation of the leg tilted forward (Fig. 1B), changing
the direction of the patellar tendon force, which potentially
may increase patellofemoral force compared with the
vertical leg position in the wall squat long at 90' knee
angle (Fig. IA). Therefore, anterior knee translation and
forward tilt of the leg may be related to increased
patellofemoral force and stress. The results of the current

study support the belief of many clinicians that anterior

knee translation beyond the toes while performing squatting
type exercises increases patellofemoral force and stress
compared with maintaining the knees over the feet.
The wall squat short and the one-leg squat both resulted
in similar amounts of anterior knee translation at maximum
knee flexion, but patellofemoral force and stress were
significantly lower in the one-leg squat compared with the
wall squat short between 90' and 70' knee angles during
the squat ascent (Figs. 4 and 5). The primary cause of the
greater patellofemoral force and stress between 90' and 70'
knee angles in the wall squat short compared with the oneleg squat was greater quadriceps force during the wall squat
short. Between 90' and 70' knee angles during the squat
ascent, the estimated quadriceps forces that were calculated
in the current study using our EMG-driven knee model
were approximately 30-40% greater in the wall squat short
compared with the one-leg squat. In contrast, between 900
and 70' knee angles during the squat ascent, the estimated

12

10
8g

g"

S6
0

'
0

S2
0
0

20

40
60
Descent

80

100

80

60

40

Ascent
Knee Flexion Angle (deg)

Wall Squat Short

Wall Squat Long

One Leg Squat

FIGURE 5-Mean (SD) patellofemoral joint stress for one-leg squat and wall squat exercises.

884

Official Journal of the American College of Sports Medicine

hftp://www.acsm-msse.orq

hamstring forces that were calculated were approximately

60-70% greater in the one-leg squat compared with the wall
squat short. One reason for greater quadriceps force and less
hamstrings force in the wall squat short compared with the
one-leg squat is because the trunk is erect in the wall squat
short (Fig. LA) and tilted forward 30-40' in the one-leg
squat (Fig. 2). The erect trunk in the wall squat short
produced a line of force from the center of the mass of the
lifter-dumbbell system (lifter's mass plus dumbbell mass)
that resulted in a relatively small hip moment arm and hip
extensor muscle moment and a relatively large knee
moment arm and knee extensor muscle moment (Fig. I B).
In contrast, the forward trunk tilt in the one-leg squat
produced a line of force from the center of the mass of the
lifter-dumbbell system that resulted in a relatively large hip
moment arm and hip extensor muscle moment and a
relatively small knee moment arm and knee extensor
muscle moment (Fig. 2).
Although friction was minimized during the wall squat
by using a smooth wall and a towel between the subject and
the wall, the normal force that the wall applied to the
subject's back during the wall squat exercises resulted in an
increased friction force on the subject as they slid down and
up the wall. This friction force acted opposite the force of
gravity during the squat descent but acted in the same
direction as the force of gravity during the squat ascent.
Therefore, the friction force made it easier for the subject to
control the rate of sliding down the wall by producing a
knee extensor torque but made it more difficult for the
subject to slide up the wall by producing a knee flexor
torque. Because the one-leg squat did not have a friction
force compare to the wall squat, this provides one plausible
explanation why quadriceps force and patellofemoral force
and stress were greater in the ascent phase of the wall squat
exercises compared with the one-leg squat.
If acceleration, whose magnitudes were very small, was
discounted during the wall squat and a static analysis was
performed at a point on the feet where the ground reaction
force acted, gravity acting on the center of mass of the lifterdumbbell system would produce a torque about the feet that
must be countered by an equal and opposite torque generated
by the normal force and static friction force that the wall
exerts on the lifter's back (Fig. IA and B). Because during
the wall squat long the heels were twice as far from the wall
compared with .the wall squat short (Fig. IA and B), the
normal force must be greater in the wall squat long
compared with the wall squat short. Because friction force
is directly proportional to the normal force, the downwardacting friction force on the subject while sliding up the wall
was greater in the wall squat long compared with the wall
squat short, making it more difficult for a subject to slide up
the wall during the wall squat long. However, because the
normal force generates a knee extensor torque during
the wall squat exercises, the greater normal force during
the wall squat long compared with the wall squat short may
have made it easier for the subject to slide up the wall

WALL SQUAT AND ONE-LEG SQUAT

during the wall squat long. Therefore, compared with the

wall squat short, during the wall squat long, the greater
friction force made it more difficult to slide up the wall but
the greater normal force made it easier to slide up the wall.
The varying and apposing actions of the normal force and
friction force during the wall squat long and the wall squat
short may help explain why the quadriceps force and
resulting patellofemoral force and stress were generally
similar between these two exercises, with the only exceptions at 600 and 90' knee angles during the squat ascent. It
is unclear why patellofemoral force and stress were
significantly greater in the wall squat long at 600 knee
angle and significantly greater in the wall squat short at
90' knee angle.
The wall squat short and long as defined in the current
study may represent two extremes in heel-to-wall distances
that can be used while performing wall squat exercises. It is
unlikely that the heel-to-wall distances used in the current
study would ever be greater when performing the wall squat
long or less when performing the wall squat short. It is
also possible that patellofemoral force and stress may be
different than the results of the current study if the wall
squat were performed with heel-to-wall distances somewhere between those used for the wall squat short and long,
and this should be the focus of additional studies. There
may be an optimal heel-to-wall distance that minimizes
patellofemoral force and stress.
Another consideration during patellofemoral rehabilitation is what knee flexion range of motion to use while
performing squat exercises. Because patellofemoral force
and stress generally increased with greater knee angles and
decreased with smaller knee angles, a more functional knee
flexion range between 00 and 500 may be more appropriate
for patellofemoral patients compared with higher knee
angles between 600 and 900. For example, during the squat
ascent phase of the wall squat short, patellofemoral force
ranged from approximately 75 to 1400 N between 00 and
500 knee angle and from approximately 2100 to 3650 N
between 60' and 90' knee angles, and patellofemoral stress
ranged from approximately 0.5 to 4.4 MPa between 0' and
500 knee angles and from approximately 5.9 to 8.9 MPa
between 600 and 900 knee angles. This same pattern of
increased patellofemoral force and stress with larger knee
angles has been reported during the barbell squat and leg
press (14,15,29,32,36). These authors reported that patellofemoral force and stress progressively increased from 00 to
approximately 900, peaking at approximately 90', and then
progressively decreasing from approximately 90' to 00.
Computer optimization techniques demonstrated similar
results during a simulated squat (7).
Peak patellofemoral force and stress magnitudes from the
current study are less than some weight-bearing exercises,
such as the barbell squat and the leg press (14), but more
than some weight-bearing functional activities, such as
walking (17) and going up and down the stairs (5).
Escamilla et al. (14) reported'peak patellofemoral force

Medicine & Science in Sports & Exercisee

885

magnitudes between 4500 and 4700 N at.900 knee angle

during the 12 RM barbell squat and leg press using healthy
subjects, resulting in patellofemoral stress magnitudes
between 11 and 12 MPa. Having healthy subjects squat
with a barbell using a 35% bodyweight load, Wallace et al.
(36) reported peak patellofemoral force magnitudes near
2500 N and patellofemoral stress magnitudes near 13
MPa, both occurring at 90' knee angle. Peak force and stress
magnitudes during the barbell squat and leg press are
approximately 25-50% greater compared with peak force
and stress magnitudes in the current study, which also
occurred at 90' knee angle. In contrast, peak patellofemoral
force and stress in healthy subjects during fast walking
reportedly are approximately 900 N and 3.13 MPa, respectively (17), which are approximately two to three times
lower than the peak force and stress magnitudes in the
current study. However, peak patellofemoral force and
stress magnitudes in healthy subjects going up and down
the stairs reportedly are approximately 2500 N and 7 MPa,
respectively (17), which are only 15-30% less compared
with the peak force and stress magnitudes in the current
study. Understanding patellofemoral force and stress magnitudes among varying resistance exercises and functional
activities is helpful to clinicians and trainers when deciding
which interventions to use for patients with PFPS.
Unlike healthy subjects, patients with PFPS exhibit
smaller patellar contact areas and greater patellofemoral
stress during some weight-bearing functional activities
(5,17). Compared with healthy individuals, patients with
PFPS had 40% smaller patellar contact areas and 110%
greater peak patellofemoral stress (6.61 MPa) during fast
walking (17). Moreover, Hinterwimmer et al. (20) reported
that patients with patellar subluxation had 40-55% smaller
patellar contact areas compared with healthy individuals,
which implies greater patellofemoral stress in these patients
compared with healthy individuals. These patellofemoral
stress data involving patients with PFPS implies that PFPS
patients may be at higher risk of experiencing pain and
discomfort while performing wall squat and one-leg squat
exercises, especially at higher knee angles where patellofemoral force and stress are greatest,. and this should be the
focus of future studies.
Unfortunately, it is currently unknown what patellofemoral force or stress magnitudes and over what time
duration can ultimately lead to patellofemoral pathology.
There are many factors that may contribute to patellofemoral
pathology, such as 1) overuse or trauma; 2) imbalance or
malalignment of the extensor mechanism, which can lead to
lateral patellar subluxation or tilt; 3) muscle weakness, such
as weak quadriceps and hip external rotators; 4) muscle
tightness, such as tight quadriceps, hamstrings, or iliotibial
band; and 5) lower extremity malalignment, such as patella
alta, genu valgum, femoral neck anteversion, excessive
Q-angle, and excessive rearfoot pronation. It can only be
surmised that relatively large patellofemoral force and stress
magnitudes over time may lead to patellofemoral pathology,

886

Official Journal of the American College of Sports Medicine

especially in individuals that exhibit some of the above

factors and thus are predisposed to patellofe'Moral problems.
Nevertheless, clinicians can use information regarding
patellofemoral force and stress magnitudes among different
weight-bearing exercises, technique variations, and functional activities to be able to make more informed decisions
regarding which exercise they choose to use during patellofemoral rehabilitation.
Patellofemoral force and stress curves were similar in
shape due to proportional increases in patellofemoral force
and patellar contact area with increased knee angles. One
exception was at higher knee angles between 70' and 900,
in which patellofemoral stress began to plateau or decrease
to a greater extent than patellofemoral force. This occurred
because although patellar contact area increased between
70' and 90', patellofemoral force did not increase proportionally but instead began to plateau or decrease. These
findings are consistent with patellofemoral force and stress
data during the barbell squat from Escamilla et al. (14) and
Salem and Powers (29). Escamilla et al. (14) reported that
patellofemoral forces increases until 75-80 knee flexion
and then began to plateau or slightly decrease. Salem and
Powers (29) reported no significant differences in patellofemoral force or stress at 75', 100', and 1100 knee flexion. It
can be concluded from these squat data that injury risk to the
patellofemoral joint may not increase with knee angles
between 750 and 1100 due to similar magnitudes in
patellofemoral stress during these knee angles, with the
benefit of increased quadriceps, hamstrings, and gastrocnemius activity when training at higher knee angles (75-1100)
compared with training at lower knee angles (0-70') (14).
There are limitations in the current study. Firstly, MRI
knee kinematic data have shown during the weight-bearing
squat that the femur moves and rotates underneath a
relatively stationary patella, and if femoral rotation is
excessive, it may result in an increase in patellofemoral
contact area, force, and stress on the contralateral patellar
facets (12,22,28). This implies that excessive medial
femoral rotation during the squat ascent may place more
stress on the lateral patellar facets, whereas excessive lateral
femoral rotation during the squat descent may place more
stress on the medial patellar facets. Unfortunately, collecting MRI knee kinematic data while performing the wall
squat or the one-leg squat is not currently possible due to
limitations in equipment design, so it is, unknown how
much femoral rotation occurs during the wall squat or the
one-leg squat, how this rotation varies among healthy
versus pathologic individuals while performing these
exercises, and if femoral rotation occurs in the wall squat
and the one-leg squat similarly to how it occurs in other
weight-bearing exercises.
Another limitation is the effect of Q-angle on patellofemoral force and stress. From cadaveric data during a
simulated squat, it was shown that an increased Q-angle
significantly caused a lateral shift and medial tilt and
rotation of the patella, which may increase patellofemoral

http://www.acsm-msse.org

force and stress (23). Unfortunately, it is currently difficult

or impossible to effectively measure lateral shift and medial
tilt and rotation of the patellar while performing squat type
exercises. Moreover, increased medial femoral rotation,
which also increases Q-angle, is also difficult to measure
accurately while squatting.
There are also limitations in the biomechanical model.
First, muscle and patellofemoral forces were estimated from
modeling techniques and not measured directly, which is
currently not possible in vivo. Second, patellofemoral stress
magnitudes were measured using patellar contact area
values from MRI data from the literature and were not
measured directly. However, the contact areas used from
the literature were determined during loaded weight-bearing
exercise in healthy male and female subjects, similar to the
current study. Moreover, the near linear and direct relationship between contact area and knee angle has been shown to
be similar among studies (2,8,20,27,30). This implies that
the patellofemoral stress curve patterns shown in Figure 5
using contact areas from the literature will be similar to
patellofemoral stress curve patterns if contact areas were
measured directly using MRI. The patellofemoral stress
patterns are important to clinicians in determining what
knee range of motions stress increases or decreases.
There are limitations regarding the magnitude of patellofemoral contact areas (and concomitant stress magnitudes),
in which the literature reports a wide array. For example,
both Patel et al. (27) and Besier et al. (2), who also used
loaded weight-bearing exercise, reported approximately
40-50% higher patellofemoral contact areas compared with
contact areas data from Salsich et al. (30). Using these larger
contact areas from Patel et al. (27) and Besier et al. (2)
would have resulted in smaller patellofemoral stress
magnitudes than those reported in the current study.
Differences in patellar contact area magnitudes and concomitant patellofemoral stress magnitudes among weight-

bearing studies are due to many factors, such as sex (males

generally have greater contact areas than females), mass
(larger individuals generally have greater contact areas than
smaller individuals), measuring techniques, and loading
magnitudes (greater loading and quadriceps contraction
results in increased contact areas and less patellofemoral
stress (2,30). Nevertheless, although patellofemoral stress
magnitudes during weight-bearing exercises or functional
activities are approximations only and not exact values,
understanding how magnitudes vary among exercises may
b6 helpful to clinicians in deciding interventions to use
during patellofemoral rehabilitation.
Finally, the current study wvas limited to healthy subjects
who were able to perform the wall squat and the one-leg
squat in the sagittal plane of motion without transverse and
frontal plane motions. Future studies are needed during the
wall squat and the one-leg squat to investigate the effects of
transverse plane rotary motions and frontal plane valgus/
varus motions on patellofemoral force and stress magnitudes, which may occur with individuals with patellofemoral pathology. Moreover, the results of this study are
specific to performing a one-leg squat holding a single
dumbbell at the chest with a forward trunk tilt of
approximately 30-40' and performing the wall squat
exercises with a dumbbell in each hand with the arms at
the side. Using different technique variations during the
one-leg squat and the wall squat exercises may affect
patellofemoral force and stress magnitudes, and this should
also be the focus of future studies.

The efforts of Dr. Bonnie Raingruber and the funding from the
National Institute of Child Health and Human Development's
Extramural Associates Research Development Award program
made this research possible. Also acknowledged are Lisa Bonacci,
Toni Burnham, Juliann Busch, Kristen D'Anna, Pete Eliopoulos, and
Ryan Mowbray for their assistance in data collection and analyses.

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TITLE: Patellofemoral Joint Force and Stress during the Wall

Squat and One-Leg Squat
SOURCE: Med Sci Sports Exercise 41 no4 Ap 2009
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