Modification of Quadriceps Femoris Muscle

Exercises During Knee Rehabilitation

T J Antich and Clive E Brewster
PHYS THER. 1986; 66:1246-1250.

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Modification of Quadriceps Femoris Muscle

Exercises During Knee Rehabilitation
T J Antich and Clive E Brewster
PHYS THER. 1986; 66:1246-1250.

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Modification of Quadriceps Femoris Muscle Exercises

During Knee Rehabilitation
T. J. ANTICH
and CLIVE E. BREWSTER
Rehabilitation of the quadriceps femoris muscle is the cornerstone of full recovery
after inactivity, immobilization, or surgery of the knee. Muscle strengthening
programs often are interrupted by patients' complaints of pain experienced during
exercise, which frequently prolong the patients' convalescence period. Specific
modifications of standard quadriceps femoris muscle exercises often allow
completely pain-free exercise, thus providing a faster progression of treatment
and a subsequently shorter rehabilitation period. The purposes of this article are
to review briefly patellofemoral biomechanics as it relates to quadriceps muscle
rehabilitation and to summarize several modifications that in our clinical experience repeatedly have reduced pain during exercise.
Key Words: Exercise therapy, Knee joint, Physical therapy.

Rehabilitation techniques that accelerate recovery time after knee injuries

or surgery for knee injuries are an integral part of the treatment process. Atrophy and hypotonia of the quadriceps
femoris muscle group frequently prolong the patient's recovery after inactivity, immobilization, and surgery of the
knee. Complaints of pain and swelling
also often hinder the physical therapist's
efforts to restore the patient's normal
muscle bulk and tone.
Through the phenomenon known as
"reflex inhibition," muscular force output and electromyographic activity generated with maximal voluntary contraction are decreased in the presence of
pain or effusion.1 The experimental
studies of deAndrade and associates using surface-electrode EMGs demonstrated reduced motor unit firing during
a maximal voluntary contraction of
muscles surrounding a joint experimentally distended with a saline solution.2
After the aspiration of excess fluid,
EMG activity with maximal voluntary
contraction increased to the preinfiltration levels.

Mr. Antich is Chief Physical Therapist, Sports

Medicine Inc, 233 E Lancaster Ave, Ardmore, PA
19003 (USA). At the time of this study, he was Staff
Physical Therapist, Kerlan-Jobe Orthopaedic
Clinic, 501 E Hardy St, Suite 200, Inglewood, CA
90301, and Research Physical Therapist, Biomechanics Laboratory, Centihela Hospital Medical
Center, 555 E Hardy St, Inglewood, CA 90307.
Mr. Brewster is Director of Physical Therapy,
Kerlan-Jobe Orthopaedic Clinic.
This article was submitted April 29, 1985; was
with the authors for revision four weeks; and was
accepted November 25, 1985.

1246

Clinically, we also have observed the

reduced ability of patients to perform
quadriceps femoris muscle exercises
while experiencing either knee-joint or
patellofemoral-joint (PFJ) pain. Although the effects of a local anesthetic
on quadriceps femoris muscle inhibition
after a meniscectomy have been measured,1 the definitive study of the effects
of using the infiltration of a local anesthetic to decrease PFJ pain and simultaneously measuring muscular output
or EMG activity has not been conducted
to date.
Our clinical experiences have brought
us in contact with many patients who
have pain while performing quadriceps
sets (QSs) and short arc quadriceps femoris muscle (SAQ) exercises. The purpose of this article is to review some
techniques that we have found to be
effective for decreasing or eliminating
knee pain in patients performing quadriceps femoris exercises. Theoretical explanations will be offered to elucidate
some of the mechanical changes that we
believe occur In the knee when the
standard exercises are modified. This
article is based on the premise that painfree quadriceps femoris strengthening
will be more productive and beneficial
to the rehabilitation programs of all patients than if pain is present with the
individual exercises.
One exercise commonly used to
strengthen the anterior thigh musculature is the QS. This exercise is performed
by isometrically contracting the quadriceps femoris muscle with the knee in a
position of full extension. This exercise,

usually performed for a 6- to 10-second

duration, has been shown to produce
greater EMG activity than either
straight-leg or active knee-extension exercises.3
We believe that isotonic quadriceps
femoris muscle exercises, performed
either through the full active range of
motion or in terminal extension, SAQ,
are superior to straight leg raising because active movement at the knee joint
places the greatest load on the quadriceps femoris muscles. In our clinic, the
weight is raised concentrically and
maintained for 10 seconds before lowering through the range eccentrically,
hence the term static weight lift (Fig. 1).
Isometrically holding for 10 seconds
may make the patient concentrate more
intensely on controlling knee extension
and ensures that he raises the weight
through the maximum available extension where the knee-joint kinematics
place the quadriceps femoris at a biomechanical disadvantage.
Before reviewing the specific modifications used for the QS and staticweight-lift exercises, we will discuss a
few general principles of both static and
dynamic tibiofemoral and patellofemoral biomechanics.
KNEE BIOMECHANICS
Patellofemoral Contact Points at
Varying Degrees of Knee Flexion
Dye contact and photographic studies
have evaluated the contact areas between the patella and the femur as the
knee flexes and extends.4 At 20 degrees
PHYSICAL THERAPY

PRACTICE

Fig. 1. Terminal extension static weight lift

performed with weight boot for quadriceps
femoris muscle strengthening.

Fig. 2. Patellofemoral contact areas at varying degrees of knee flexion. (Adapted from
Goodfellow et al.4)

Fig. 3. Ankle dorsiflexion combined with

quadriceps femoris muscle setting to decrease patellofemoral joint pain.

stability will be disrupted in patients

with patella alta, hypotrophic femoral
intercondylar grooves, patellar subluxation, and hyperelastic connective tissues.
Terminal Extension

cf flexion, only the inferior pole of the

patella is in contact with the femur. The
point of contact moves proximally on
the patella as the knee flexes to 45 degrees and then to 90 degrees (Fig. 2). At
full flexion, only the odd facet and the
lateral facet approximate the medial and
lateral femoral condyles, respectively.
Patients with localized degenerative
changes in one part of the retropatellar
articular cartilage may experience pain
in one position but not at another, depending on whether the compression
forces on the damaged area are increased or decreased.
Osseous Stability of the Patella
in the Intercondylar Groove
The more stable configuration of the
patella in the femoral intercondylar
groove occurs with increasing angles of
knee flexion, and in the last 15 to 20
degrees of extension the patella rides
proximally out of the groove. Mediallateral stability must depend on the
static tautness of the retinacula and the
dynamic control of the vastus medialis
oblique (VMO) muscle in the absence
of osseous congruence. This normal PFJ
Volume 66 / Number 8, August 1986

Tibial external rotation occurs at the

end of terminal extension ROM in a
foot-free position. If active hyperextension is attainable, if the patient has a
laterally located tibial tubercle, or if an
abnormally excessive valgus malalignment of the knee exists, excessive lateral
excursion of the patella may result at
the end of the ROM.
Role of the VMO in Normal
Dynamic Patellar Biomechanics
Oblique fibers of the VMO muscle
inserting at 55 degrees to the long axis
of the femur primarily are responsible
for maintaining proper patellar tracking.5 Lieb and Perry demonstrated that
this tracking is the muscle fibers' only
function because structurally the fibers
are not in the proper position to act as
a synergist to the rest of the muscle
group functioning as a knee extensor.6
Clinically, we often have observed PFJ
pain to be related to VMO muscle hypotonia. Experimental infiltration of the
knee joint with a saline solution demonstrated greater inhibition of muscle
activity in the VMO than in the rectus
femoris or vastus lateralis.7

Anterior-Posterior Tibial
Displacement
The cruciate ligaments are the primary static restraints against tibiofemoral sagittal shear forces. The role of
the quadriceps femoris and hamstring
muscles as the dynamic synergist to the
posterior cruciate ligament (PCL) and
anterior cruciate ligament (ACL), respectively, has been stressed in rehabilitation by Brewster et al8 and by other
physical therapists (K. R. Glick, personal communication, July 1983). Although injuries to the ACL outnumber
those to its posterior counterpart by a
ratio of 10:1, quadriceps femoris muscle
contraction in the ACL-deficient or
ACL-reconstructed knee may result in
excessive anterior tibial displacement
with stress being dissipated to other secondary restraints or to the new graft,
either of which may result in pain.

MODIFICATIONS
Ankle Dorsiflexion
The most successful modification of
the QS exercise for decreasing PFJ pain
is active dorsiflexion (DF) of the ankle
before contraction of the quadriceps
femoris muscles (Fig. 3). Many academicians teach ankle DF as a standard
part of the exercise to generate an increased contraction force. This result,
however, was not substantiated by our
1247

Fig. 4. Avoiding full extension with a small

wedge.

Fig. 7. Assessment of medial manual tracking; a, superficial tissues are pushed laterally
and b, the deeper retinaculum is pulled medially.

from having the knee positioned in varying degrees of flexion. Figure 4 illustrates the use of a small wedge under
the knee to reduce PFJ pain. This modification may benefit patients with inflammation of either the plica or the
infrapatellar fat pads because a QS in
the position of full extension often aggravates those conditions. Those patients with patellar tracking problems
may benefit from the slightly improved
bony congruity of the patella in the femoral groove when exercising isometrically in a few degrees of flexion.
Patients with a rupture of the ACL or
with post-ACL reconstruction always
should use at least a small wedge when
performing QS exercises. Maintaining
the knee in slight flexion prevents hyperextension if the heel is kept on the
mat and also decreases stress on the
posterolateral bundle of the ACL,9 the
secondary restraints, and the ligament
graft.
Ankle Dorsiflexion with Inversion
Actively inverting the foot in combination with ankle DF may benefit patients with patellar malalignment when
DF alone is ineffective. Dorsiflexing the
ankle locks the talocrural joint, and the
subsequent inversion prevents excessive
external rotation of the tibia, moving
the tubercle slightly more medially (Fig.
5). By decreasing the lateral shear forces
exerted on the patella and the medial
retinaculum, parapatellar pain may be
reduced effectively.10

Fig. 5. Decreasing the Q angle by inverting

and dorsiflexing the ankle.

Fig. 6. Isometric hip adduction before quadriceps femoris muscle exercises.

Isometric Hip Adduction

own research in which we compared
EMG outputs recorded using indwelling
wire electrodes (D. R. Moynes et al,
unpublished data, 1982). We believe
that active ankle DF actually may inhibit contraction of the quadriceps femoris muscle because it is part of the
flexor withdrawal reflex with associated
hamstring muscle facilitation and quadriceps femoris muscle inhibition. This
hypothesis may be supported by our
clinical observations that pain persists
when the quadriceps femoris muscles
are contracted with a relaxed ankle but
is relieved when active DF (with a reduction of quadriceps femoris strength
and, therefore, of PFJ pain) precedes the
contraction. The decreased pain may be
caused by the decreased force of the
1248

quadriceps femoris contraction.

Another possible reason that pain
may be reduced with ankle DF is the
resultant passive stretch on the antagonistic calf musculature. The position of
the knee in full extension exerts maximal stretch on the gastrocnemius muscle because it is a two-joint muscle.
Crossing the posterior aspect of the knee
joint, the gastrocnemius muscle may
flex the knee passively a slight amount
because the ankle is in DF, thus eliminating pain at full extension.
Use of Small Wedge
Patients who have either knee-joint
effusion or pain with the standard QS
position at full extension may benefit

Patients with PFJ symptoms may

achieve pain relief by performing isometric hip adduction exercises before
performing knee-extension exercises
(Fig. 6). Although isometrically adducing the hips (2 sets of 10 repetitions,
each of 10 seconds' duration) does not
elicit a VMO muscle contraction automatically, performing hip adduction exercises before knee-extension exercises
has been observed to result in decreased
pain (D. R. Moynes et al, unpublished
data, 1982). Because the VMO muscle
originates, in part, from the fascia overlying the adductor magnus muscle,11 exercising this larger muscle first may generate tension within it, thereby placing
the VMO muscle at a better mechanical
advantage and resulting in decreased lateral shearing.
PHYSICAL THERAPY

PRACTICE

Ice Before Exercise

Fig. 9. Starting with the knee in more flexion allows the vastus medialis oblique muscle
time to contract earlier and prevent lateral
tracking problems.

Fig. 8. Electromuscular stimulation of the

vastus medialis oblique muscle in conjunction
with isometric exercises.

Electromuscular Stimulation
Electromuscular stimulation is a valuable adjunct to quadriceps femoris
muscle exercises for decreasing peripatellar pain resulting from selective weakness of the VMO muscle. An evaluative
technique called medial manual tracking can identify those patients who may
achieve pain relief with the use of electromuscular stimulation. The therapist
first places his hand on the medial aspect
of the knee joint, dropping his thumb
just medial and superior to the patella
(directly overlying the VMO muscle).
Pushing the superficial skin and subcutaneous layers laterally (Fig. 7a), he then
exerts deeper pressure and, feeling the
underlying retinaculum, pulls back medially (Fig. 7b). After the patient has
contracted his quadriceps femoris, the
therapist then should then evaluate the
patient's perceived level of pain. For
patients with a dystrophic VMO muscle
or stretched medial stabilizers, electromuscular stimulation actually takes the
place of the absent or reduced VMO
muscle contraction. If pain is relieved
substantially by medial manual tracking, the use of electromuscular stimulation on the VMO muscle is likely to be
successful.
When administering electromuscular
stimulation for VMO muscle strengthening, the best results may be obtained
by using electrodes of different sizes.
The smaller electrode should be placed
over the motor point of the VMO muscle, resulting in a higher current density
under this pad (Fig. 8). The duty cycle
may be adjusted in most units to correspond to the length of the contraction
Volume 66 / Number 8, August 1986

desired. Active quadriceps femoris muscle exercises then are performed, augmented by the electromuscular stimulation.
Static Weight Lifts
Standard static weight lifts are performed using ankle cuff weights or a
weight boot over a roll about 6 in in
diameter, thus using a ROM of about
35 degrees to full extension. All of the
previously discussed modifications (ankle DF, ankle DF with inversion, wedge,
electromuscular stimulation) may be
used with this form of isotonic muscle
strengthening.
Pain may be eliminated with static
weight lifts if the painful location within
the arc of motion can be determined.
Pain may be experienced during either
concentric or eccentric movements, or
both; at the beginning of ROM; or at
the end of ROM. In 151 cases of PFJ
symptoms studied in our clinic, more
knees were symptomatic of pain with
concentric contractions (11%) than with
eccentric contractions (5%), although
75% exhibited no pain with active knee
extension through a 90-degree arc.12
Starting in More Flexion
Clinically, more patients have pain at
full extension than at other positions in
the ROM. This position may be modified by using larger rolls to increase the
height of the fulcrum (Fig. 9). Beginning
with the knee in a more flexed position
affords the patient a position of better
PFJ osseous stability because the patella
is seated better in the intercondylar
groove. In patients with "quadriceps reversal"13 or delayed firing of the VMO
muscle during active ROM, the greater
range allows a longer time for activation
of this dynamic medial stabilizer to reduce lateral tracking problems.

If none of the aforementioned modifications either substantially reduce discomfort with exercise or completely
eliminate pain, the knee may be treated
with ice for 10 minutes before exercise
is performed. Depending on the level of
pain after cryotherapy, the therapist
must use clinical judgment and experience to determine whether exercise performed with pain will aggravate the patient's condition.
Hamstring Cocontraction
Patients with increased anterior excursion of the tibia on the femur
(because of ACL insufficiency) during
isotonic quadriceps femoris muscle exercises should be instructed to contract
the hamstring muscles for one second
before lifting the leg. Coactivation of the
knee flexor muscles during knee-extension exercises decreases the anterior
shear of the tibia and provides for more
normal biomechanical functioning because of better maintenance of the axis
of rotation.
CONCLUSIONS
Quadriceps femoris muscle strengthening forms the foundation for both
nonsurgical and postoperative rehabilitation programs. Goldfuss et al reported
that passive medial and lateral kneejoint opening to externally applied force
was reduced in actively contracted
quadriceps femoris muscles when compared with that instability measured in
a relaxed state.14
Optimal quadriceps femoris muscle
contractions are achieved best in the
absence of pain. We have reviewed our
methods of reducing pain in patients
performing quadriceps femoris muscle
exercises and hope that some of the
techniques discussed may not only improve the quality of patient care, but
also stimulate further related research.
Acknowledgments. We acknowledge the assistance of the following
members of the Kerlan-Jobe Orthopaedic Clinic Physical Therapy Research Committee in the preparation of
this manuscript: Celeste Criswell Randall, MS, RPT; Roxie A. Westbrook,
RPT; and Matthew C. Morrissey, MA,
RPT.
1249

REFERENCES
1. Stokes M, Young A: Investigations of quadriceps inhibition: Implication for clinical practice.
Physiotherapy 70:425-428,1984
2. deAndrade JR, Grant C, Dixon A St. J: Joint
distension and reflex muscle inhibition in the
knees. J Bone Joint Surg [Am] 47:313-322,
1965
3. Pocock GS: Electromyographic study of the
quadriceps during resistive exercise. J Amer
Phys Ther Assoc 43:427-434,1963
4. Goodfellow JW, Hungerford DS, Zindel M: Patello-femoral joint mechanics and pathology: 1.
Functional anatomy of the patello-femoral joint.
J Bone Joint Surg [Br] 58:287-290,1976
5. Lieb FJ, Perry J: Quadriceps function: An anatomical and mechanical study using amputated
limbs. J Bone Joint Surg [Am] 50:1535-1548,
1968
6. Lieb FJ, Perry J: Quadriceps function: An electromyographic study under isometric conditions. J Bone Joint Surg [Am] 53:749-758,
1971
7. Spencer JD, Hayes KC, Alexander lJ: Knee
joint effusion and quadriceps reflex inhibition in
man. Arch Phys Med Rehabil 65:171-177,
1984

8. Brewster CE, Moynes DR, Jobe FW: Rehabilitation for anterior cruciate reconstruction. Journal of Orthopaedic and Sports Physical Therapy 5:121-126,1983
9. Paulos L, Noyes FR, Grood E, et al: Knee
rehabilitation after anterior cruciate ligament
reconstruction and repair. Am J Sports Med
9:140-149, 1981
10. Olerud C, Berg P: The variation of the Q angle
with different positions of the foot. Clin Orthop
191:162-165,1984
11. Bose K, Kanagasuntheram R: Vastus medialis
oblique: An anatomic and physiologic study.
Orthopedics 3:880-889,1980
12. Antich TJ, Randall CC, Westbrook RA, et al:
Evaluation of knee extensor -mechanism disorders: Clinical presentation of 112 patients.
Journal of Orthopaedic and Sports Physical
Therapy, to be published
13. Williams JGP, Street M: Sequential faradism in
quadriceps
rehabilitation.
Physiotherapy
62:252-254,1976
14. Goldfuss AJ, Morehouse CA, LeVeau BF: Effect of muscular tension on knee stability. Med
Sci Sports 5:267-271,1973

Commentary
The opportunity to write a commentary may be viewed as being asked for a
second opinion. A second opinion may
agree with or disagree with the initial
interpretation. This commentary is a
discussion of only those concepts with
which I disagree that were presented in
the article.
The term static weight lift is misleading. A more accurate term for the exercise might be dynamic-static-dynamic
weight lift. Because a subject performs
an isometric contraction and concentrates intensely does not ensure that he
will lift the weight through the maximum available range of motion. The
ability to raise the weight through the
available ROM also depends on whether
enough innervated and cross-sectional
areas of muscle tissue exists.
The authors suggest that active dorsiflexion and inversion of the foot prevent
excessive tibial external rotation, resulting in a more medial displacement of
the tubercle (tuberosity) and providing
a beneficial effect on the valgus movement of the patella during knee extension. Although the authors cite the research of Olerud and Berg1 to support
this concept, they do not mention that
Olerud and Berg's research was conducted in a closed kinetic chain with the
subject's foot on the ground. The modified quadriceps femoris muscle exercise
1250

program presented in the article appears

to use an open-kinetic-chain type of activity. The biomechanics of tibial rotation and subtalar motion are distinctly
different in an open kinetic chain as
compared with a closed kinetic chain.2,3
If the knee is not in a closed pack position, then the motion of inversion of the
foot may prevent excessive tibial external rotation. In an open kinetic chain,
however, when the tibia is in the last few
degrees of extension or the first few degrees of flexion, the tibial rotation is a
function of the arthrokinematics of the
knee joint and not of the position of the
foot.4,5 The medial rotation of the tibial
tubercle observed with inversion of the
foot in an open kinetic chain probably
is a function of femoral internal rotation
that may result if the subject is instructed to rotate his foot inwardly.
The authors do not mention the reasons for exercising the knee in a closed
kinetic chain in their discussion of their
modifications of quadriceps femoris
muscle exercises. Hungerford and Lennox have reported a biomechanical
analysis demonstrating less patellofemoral contact stress from 30 to 60 degrees
of knee flexion in a closed kinetic chain
versus an open kinetic chain.6 As the
knee flexes, patellofemoral-joint-reaction (PFJR) forces increase, but so does
the patellofemoral contact area, which

aids in the distribution of PFJR forces

so that patellofemoral stress is decreased.7
Preliminary data also are available
supporting the use of closed-kineticchain exercises for patients with anterior
cruciate ligament (ACL) injuries.7 Using
an in vivo strain gage, Henning et al
demonstrated with values normalized to
the individual that one of the activities
that caused the greatest strain to be
placed on the ACL was knee-extension
exercises using a 20-lb weight boot in
the range of full extension to 22 degrees
of flexion.7 The ACL was subjected to
much less strain during a half-squat exercise.
Perhaps, quadriceps femoris muscle
exercises should be modified to include
more closed-kinetic-chain types of activities such as the lateral or anterior stepup exercises.8,9 In my experience, if the
patient is allowed to pronate during the
lateral step-up exercise, the valgus knee
angle is increased, which is believed to
be detrimental to patients with patellofemoral disorders.10
In an open kinetic chain, patellofemoral contact stress is greatest from
55 degrees of flexion to full extension.6
The modification of the static weight lift
proposed by the authors to be performed
from 35 degrees offlexionto full extension in an open kinetic chain, therefore,
is in the ROM that creates the greatest,
and possibly harmful, patellofemoral
contact stress. The authors suggest that
the static weight lift may be initiated in
greater degrees of flexion because it affords better patellofemoral osseous stability. The study of Hungerford and
Lennox provides an alternative rationale for using greater degrees of flexion
during open-kinetic-chain knee extension in that patellofemoral contact stress
is less from 55 to 75 degrees of flexion.6
With open-kinetic-chain, knee-extension resistive exercise, therefore, the
greater the degree of knee flexion, the
less the patellofemoral contact stress.
In a qualified statement, the authors
suggest that electromuscular stimulation
is a valuable adjunct to quadriceps femoris muscle exercises for strengthening
the vastus medialis oblique muscle. Although the validity of this statement
cannot be proven because measuring in
vivo the tension-generating capability of
an individual quadriceps femoris muscle is impossible, I will assume that the
vastus medialis oblique muscle can be
strengthened selectively with knee-exPHYSICAL THERAPY