THE EFFECT OF CLOSED-KINETIC CHAIN EXERCISES
AND OPEN-KINETIC CHAIN EXERCISE ON THE
MUSCLE ACTIVITY OF VASTUS MEDIALIS
OBLIQUE AND VASTUS LATERALIS
SIAN E. IRISH, ADAM J. MILLWARD, JAMES WRIDE, BERNHARD M. HAAS,
School of Health Professions, University of Plymouth, Plymouth, Devon, England, United Kingdom
ABSTRACT
Irish, SE, Millward, AJ, Wride, J, Haas, BM, and Shum, GLK. The
effect of closed-kinetic chain exercises and open-kinetic chain
exercise on the muscle activity of vastus medialis oblique
and vastus lateralis. J Strength Cond Res 24(5): 1256–1262,
2010—Patellofemoral pain syndrome (PFPS) is one of the most
prevalent musculoskeletal conditions of the lower limb. The
muscle imbalance between the vastus medialis oblique (VMO)
and vastus lateralis (VL) muscles is one of the main factors
leading to the development of PFPS. The disparity in research
and the necessity to add to the existing literature base led to
the development of this study. The aim of this study was
to investigate the effect of 2 closed kinetic chain exercises
and 1 open kinetic chain exercise on VMO and VL muscle
activity. Twenty-two healthy asymptomatic individuals partici-
pated in this study. The surface electromyography (EMG) of
VMO and VL was measured and used to calculate the VMO:VL
ratio during 3 different quadriceps-strengthening exercises
(a double leg squat with isometric hip adduction exercise, an
open kinetic chain knee extension exercise, and a lunge exercise).
The double leg squat with isometric hip adduction exercise was
shown to produce a significantly greater VMO:VL ratio (1.14:1)
than the other 2 exercises (p = 0.015 and p = 0.005). The open
kinetic chain knee extension exercises produced significantly
greater activation of VL than the lunge exercise (p = 0.001 and p
= 0.036). The lunge exercise produced the VMO:VL ratio
(1.18:1) closest to the idealized ratio of 1:1. Potential clinical
recommendations can be made proposing the lunge exercise as
a key tool in early rehabilitation when restoring preferential
VMO:VL ratio is essential. The double leg squat with isometric
Address correspondence to Dr. Gary Shum, gary.shum@plymouth.ac.uk.
The study was approved by the Human Ethics Sub-Committee of the
University of Plymouth, United Kingdom.
24(5)/1256–1262
Journal of Strength and Conditioning Research
Ó 2010 National Strength and Conditioning Association
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1256 Journal of Strength and Conditioning Research
AND GARY L.K. SHUM
hip adduction exercise would be useful in maintaining correct
patella tracking and selectively strengthening VMO.
KEY WORDS patellofemoral pain, quadriceps exercises,
strength training
INTRODUCTION
P
atellofemoral pain syndrome (PFPS) is a disorder
related to peripatellar or retropatellar pain (5) and
it is 1 of the most prevalent musculoskeletal con-
ditions of the lower limb, with incidences esti-
mated as high as 25% within the general population and 60%
within the athletic population (28). Vastus medialis oblique
(VMO) and vastus lateralis (VL) are the 2 principle muscles
that work synergistically to stabilize the patella during
dynamic knee extension. The ratio of VMO:VL has a
theoretical ideal of 1:1 (24), and research has shown this ratio
to be as low as 0.54:1 in people with PFPS (23). Any dis-
turbance in the VMO:VL ratio, owing to a decreased medial
pull, may lead to patella maltracking (1,15) and consequently
inflammation, pain, premature cartilage degeneration, and
ultimately PFPS (26). It has been suggested that reestablish-
ing this imbalance can be achieved by strengthening exer-
cises specifically targeting VMO. The existing evidence base
supports this as a successful method of preventing and
reducing PFPS (19,21,26), and current literature is flooded
with research concerning the best exercises to preferentially
activate VMO. Nonetheless, debate still remains as to an
agreed ‘‘gold standard’’ exercise and controversy litters the
evidence base.
Contradictory evidence surrounds the specific use of hip
position to activate VMO. Hanten and Schulthies (14)
suggested that the addition of hip adduction is crucial to
selectively activate VMO. Anatomic cadaver studies have
shown that fibers from the VMO originate from the distal
part of the adductor magnus and by contracting the
adductors the VMO is provided with a ‘‘stable origin from
which to contract’’ (14). Hip adduction also generates
a stretch of the VMO fibers, which adjusts the length tension
properties of the muscle and thus will increase the

contraction force. In stark contrast, findings from Coqueiro
et al (6) found that during a standard semi-squat exercise,
there was a significant difference between VL and VMO
electromyographic (EMG) activity in favor of VL. Different
conclusions were made by Earl et al (11), who found that
combining isometric hip adduction with a closed-chain mini-
squat produced greater overall quadriceps activity compared
to a standard mini-squat. Previous literature highlighted
problems with failure to standardize adduction forces (6);
therefore, interpretation of findings should be made with
caution.
Open-chain leg extension exercises are often a routine
method of selectively targeting VMO in clinical practice
(13,20). There is little supporting evidence to verify its use,
and within the available literature common consensus is far
from conclusive. The established definition of an open kinetic
chain exercise is a single joint movement that is performed in
a nonweightbearing position with a free distal extremity.
Conversely, closed-chain exercises are considered multijoint
movements performed in a weightbearing or simulated
weightbearing position with a fixed distal extremity (25).
Although research is sparse, there are clinical situations when
open-chain exercises may be the more appropriate treatment
option. For example, those with a large body mass index (BMI)
may be at risk of increased levels of load being placed through
the joint and, because of reduced exercise tolerance, this may
cause difficulty with following closed change programs.
Additionally, open-chain knee extensions may be the only
possible rehabilitation option for patients with cognitive
difficulties, with multiple pathologies, or who are at risk of falls.
Laprade et al. (20) showed that VMO was more active than
VL during knee extensions. Brownstein et al (3) reported that
VMO was most active at 60 to 90 degrees of knee flexion
in a nonweightbearing position and least active with the
knee fully extended. Additionally, Tang et al (27) reported
that in asymptomatic participants a VMO:VL ratio of greater
than 1 was evident during open-chain knee extensions at
75 and 90 degrees of knee flexion. Patients with PFPS were
also shown to have an improved ratio during the eccentric
phase at 60 degrees, 75 degrees, and 90 degrees of knee
flexion (3).Comparisons to other literature need to be made
with caution because muscle force was measured via a
dynamometer as opposed to EMG activity.
Current research has not yet explored the effectiveness of
incorporating lunge exercises into the rehabilitation of VMO.
The significance of such an exercise can only be hypothesized
based on its biomechanics. Suggestions have been put
forward that closed kinetic chain exercises, such as squatting
or lunging, utilize both multiple-joint proprioceptive reac-
tions and muscular cocontraction. For this reason they are
assumed to be a more functional intervention than open-
chain exercises (27). A recent study also suggested that
a closed kinetic chain exercise with a short arc (,45 degrees)
is the best exercise to strengthen the quadriceps muscles
group because it induced the least joint reaction force (27).
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Journal of Strength and Conditioning Research | www.nsca-jscr.org
The study of Tang et al (27), however, showed that the
greatest activation of VMO is actually achieved at 60 degrees
of flexion in a weightbearing position. The authors used a
squat-to-stand closed kinetic chain exercise with knee flexion
angles ranging from 15 degrees to 90 degrees. Findings
also showed that a ratio of greater than 1 was present at
60 degrees of knee flexion. This has been confirmed by other
studies (17). For this reason, it can be anticipated that lunge
exercise may be beneficial in the retraining of the VMO
muscles.
The aims of this study were to investigate the effect of the
tested exercises on the activation of VMO:VL and to ascertain
which exercise preferentially activates VMO in relation to VL.
The choice of exercises aims to compare 2 exercises that are
commonplace in rehabilitation (i.e., open-chain leg extension
and squat with isometric hip adduction) and add an exercise
that has never been studied but is potentially a valuable addition
to VMO strengthening. The lunge exercise may offer a simple
alternative closed-chain exercise that is highly functional and,
because of the increased weightbearing on the limb doing the
exercise, may result in a substantial VMO contraction.
METHODS
Experimental Approach to Problem
The muscle activities of the VMO and VL were measured in
22 healthy, asymptomatic subjects in 3 quadriceps muscle-
strengthening exercises. Surface EMG signals were utilized to
investigate the differences among the 3 exercises tested. This
study was a repeated-measures design and took place in
a university laboratory setting.
The electrical activity of VMO and VL was recorded using
surface EMG electrodes (Biometrics Ltd, SX230, Gwent,
United Kingdom), with a set interelectrode distance of
20 mm. Surface electrodes have been shown to be influenced
by crosstalk from directly adjacent muscles (4), and the con-
tracting muscle can potentially change the EMG signal as it
may consequentially move the electrode. Farina et al. (12)
reported that surface EMG is influenced by motor unit
discharge rates and muscle fiber membrane characteristics.
Therefore, participants were swabbed with alcohol wipes
prior to electrode placement and BMI was limited to 30 (26).
Results were recorded and filtered using Biometric software.
To enable normalization of the EMG findings, a maximal
voluntary contraction (MVC) was carried out (3). The maxi-
mal voluntary contractions of VMO and VL were determined
by using the mean average of 3 static quadriceps maximal
isometric contractions at 45 degrees of knee flexion. A 30-
second rest period between each contraction was included
to eliminate possible fatigue affects. Prior to data analysis,
all results were normalized by calculating them as a percent-
age of their MVC (%MVC). The average value of %MVC
for each exercise was then calculated as the arithmetic mean
of the 3 values. These data then were used to calculate the
VMO:VL ratio.
VOLUME 24 | NUMBER 5 | MAY 2010 | 1257
Effect of Kinetic Chain Exercises on Muscle Activity

EMG surface electrodes were placed on the muscle belly of

VMO, 4 cm superior and 4 cm medial to the supromedial
boarder of patella at approximately 55 degrees to the long axis
of the femur. The VL electrode was placed 10 cm superior
and 6–8 cm lateral to the superior lateral boarder of the
patella and orientated 15 degrees to the vertical (16). A
reference electrode was situated at the tibial tubercle to
normalize background electrical activity. Electrodes were
attached using double-sided tape, with additional taping over
the whole electrode site. This was to ensure the best possible
skin contact to limit skin impedance.

Subjects
Twenty-two healthy asymptomatic subjects participated in
this study (11 men, 11 women, age = 25.06 6 4.67; height =
1.73 6 0.09 m, mass = 65.57 6 9.38 kg, BMI = 23.51 6 2.70). Figure 1. Open kinetic chain knee extension exercise.
Participants were excluded if their age was younger than 18 or
older than 40; if they had any current or previous history of
knee or lower limb injury (18); if they had any history of knee
This exercise was achieved by compression of a folded pillow
pain on ascending or descending stairs, squatting, kneeling,
placed between the medial joint lines of the knees. The
prolonged sitting, hopping, or jumping within the last
exercise was performed with the back flat against a
3 months (7,10); or if their BMI was larger than thirty
wall while squatting to 45 degrees (6) (Figure 2). The
(26). The study was undertaken in the months of March and
adduction force was maintained throughout the entire
April; however, this should not influence the repeatability of
exercise, and a pillow was chosen to maximize comfort
the study because the setting was in closed conditions much
because there was concern that a more rigid object
like an outpatient or ward setting. Participants had a range
could lead to discomfort, thus inhibiting muscle
of fitness levels and training backgrounds. The study was
activity and affecting electrode placement.
approved by the Human Ethics Sub-Committee of the
iii. Lunge exercise (closed kinetic chain)
University of Plymouth, United Kingdom. All participants
A lunge exercise was performed with the measured leg
were older than 18 years old and were informed of the
foremost in a stride stance with both knees fully
procedures, experimental risks, rationale, and their role.
extended. Feet were hip-width apart and both feet were
A consent form was signed prior to the investigation and
angled forward. The measured knee was flexed to
participants were informed of their right to withdraw.
45 degrees (Figure 3), followed by the return to full
extension while maintaining the knee in a neutral
Procedures
alignment over the second metatarsal. The rear knee
Prior to the study, participants performed a 5-minute sub-
remained in full extension throughout the exercise, and
maximal warm-up using a cycle ergometer, working at a
both heels remained in contact with the floor.
rating of 11 or 12 on the Borg rating of perceived exertion
scale (2,9). The scale ranged from 6 to 20, where 6 meant ‘‘no Statistical Analyses
exertion at all,’’ 20 meant ‘‘maximal exertion,’’ and 11 cor- The dependent variables in this study were the %MVC of
responded to ‘‘light work.’’ Patients were instructed to reflect VMO and VL of the exercised tested and the VMO:VL ratio
on how heavy and strenuous the warm-up felt and must of each exercise. If the VMO:VL ratio was greater than 1, it
relate it to a combination of all sensations of physical stress, implied that the VMO had a higher muscle activity than that
effort, and fatigue. The possibility of exercise induced injury of VL and pulled the patella medially. A repeated-measures
was therefore limited. analysis of variance test was used to examine any differences
This study investigated the following quadriceps strength- in these variables among the 3 exercises. A post hoc least
ening exercises with no external additional weight. significant difference test was performed with the level of
i. Open kinetic chain knee extension exercise significance set at p = 0.05. The consistency of the dependent
The subject was seated on a raised platform with both feet variables over the 3 trials within each subject was determined
off the floor and thighs supported to the popliteal by using the intraclass correlation coefficient (ICC) (1,3).
fossa (Figure 1). A single leg extension was performed
between the angles of 90 degrees to 0 degrees knee RESULTS
flexion (27). The mean ICCs (1,3) of the dependent variables were 0.94 6
ii. Double leg squat with isometric hip adduction exercise (closed 0.02, indicating that there were no significant differences in
kinetic chain) the variables among the 3 trials. It is concluded that the
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1258 Journal of Strength and Conditioning Research

 3 exercises (Table 1, p . 0.05).
and VMO:VL ratios between males and females for
There was no significant difference in muscle recruitment
enough to reveal any significant differences in this study.
effect size was found to be 0.87, which was sufficiently large
ization of results. The power of this study was 0.62 and the
results obtained were highly repeatable, allowing general-
Figure 3. Lunge exercise.

Figure 2. Double leg squat with isometric hip adduction exercise.

Journal of Strength and Conditioning Research

the
TABLE 1. The electromyographic values for muscle activity for the open-chain knee extension exercise, the double leg squat with isometric hip adduction exercise,
and the lunge exercise.

Double leg squat with isometric hip

Open-chain knee extension exercise adduction exercise Lunge exercise
Exercise
VOLUME 24 | NUMBER 5 | MAY 2010 |

Muscle VMO VL VMO:VL VMO VL VMO:VL VMO VL VMO:VL

Male (n = 11) 0.62 6 0.32 0.89 6 0.44† 0.70:1 0.99 6 0.47* 0.84 6 0.43† 1.17:1‡ 0.63 6 0.35 0.55 6 0.33 1.14:1‡
Female (n = 11) 0.68 6 0.48 0.93 6 0.42† 0.73:1 0.97 6 0.75* 0.82 6 0.40† 1.18:1‡ 0.60 6 0.37 0.52 6 0.15 1.15:1‡
Total (n = 22) 0.65 6 0.38 0.90 6 0.84† 0.72:1 0.98 6 0.62* 0.83 6 0.44† 1.18:1‡ 0.61 6 0.36 0.53 6 0.26 1.14:1‡
VMO = vastus medialis oblique; VL = vastus lateralis.
No significant difference existed in muscle recruitment or VMO:VL ratios between males and females for 3 exercises (p . 0.05).
*Significantly greater VMO activation when compared with the open-chain leg extension exercise (p = 0.015) and the lunge exercise (p = 0.005).

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†Significantly greater VL activation than the lunge exercise. (Double leg squat with isometric hip adduction exercise, p = 0.001; open chain leg extension exercise, p = 0.036.)

| www.nsca-jscr.org
‡Significantly greater VMO:VL ratio than that of open-chain leg extension exercise. (Double leg squat with isometric hip adduction exercise, p = 0.019; open-chain leg extension
exercise p = 0.045).
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Effect of Kinetic Chain Exercises on Muscle Activity
Figure 4. The mean normalized electromyographic (EMG) activity of vastus medialis oblique (VMO) and vastus
lateralis (VL) with error bars showing standard deviation during 3 exercises. *p , 0.05, There was a significantly
greater VMO activation in comparison with the Open chain leg extension (p = 0.015) and Lunge exercise (p =
0.005). †p , 0.05, There was a significantly greater VL activation than the Lunge exercise. (Squat with isometric hip metric hip adduction exercise
adduction p = 0.001; Open chain leg extension p = 0.036).
Activation of VMO
Double leg squat exercise showed a significantly greater
activation of VMO in comparison with the open kinetic chain
knee extension exercise (p = 0.015) and lunge exercise
(p = 0.005) (Table 1, Figure 4). There were no significant
differences between the double leg squat with isometric hip
adduction exercise and the lunge exercise in activating VMO
(p = 0.602).
Activation of VL
The open kinetic chain knee extension exercise and double
leg squat exercise showed significantly greater activation
of VL in comparison with the lunge exercise (p = 0.001 and
p = 0.036) (Table 1, Figure 4). However, whereas the
open-chain knee extension showed a greater VL activation
than the double leg squat exercise, this was not significant
(p . 0.05).
VMO:VL Ratio
Both the double leg squat and lunge exercises showed a
significantly greater VMO:VL ratio (p = 0.019 and p = 0.045)
than open-chain knee extension exercise (Table 1). No
significant difference was seen between double leg squat
and lunge exercises in the VMO:VL ratio. Open-chain knee
extension exercise was shown to preferentially activate VL
resulting in a ratio of 0.72:1 (Table 1).
DISCUSSION
This study has added to the existing debate concerning the
best exercise to selectively activate VMO in relation to VL.
The conclusions drawn have allowed us to reject the null
hypothesis and make possible recommendations for practice.
Results have shown that the double leg squat with isometric
hip adduction exercise produced a significantly greater
activation of VMO than the other 2 exercises tested. These
findings are in line with a previous study (14), which also
concluded that this was the most effective exercise for
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1260 Journal of Strength and Conditioning Research
activation of VMO. Coqueiro
et al (6) reported that double
leg squat exercises increased
activation in both VMO and
VL, thereby producing a ratio
closer to the idealized ratio of
1:1 (24). This is in agreement
with our findings because
VMO and VL both achieved
a significant increase in activity.
Coquerio et al (6) showed no
significant preferential activa-
tion of VMO over VL; how-
ever, our study did show that
the double leg squat with iso-
did preferentially activate VMO
(Table 1), producing a ratio of
greater than 1.
The open kinetic chain knee extension exercise was shown
to produce significant activation of VL instead of VMO,
resulting in a VMO:VL of less than 1. This concurs with the
findings of Tang et al (27), in which, during an isokinetic open
kinetic chain knee extension exercise, a VMO:VL ratio of less
than 1, 15 to 60 degrees was reported. Therefore, it can be
anticipated that open-chain knee extension exercises may
have little beneficial effect or even an adverse effect on PFPS
rehabilitation because the decreased VMO:VL ratio 0.72:1
suggests that open kinetic chain knee extension exercise may
induce excessive lateral tracking of the patella.
The pathology of PFPS is generally accepted to result from
VMO weakness and disruption of the VMO:VL ratio (19,21,
26). The high muscle activity and preferential VMO:VL ratio
(1.14:1) generated by the double leg squat with isometric hip
adduction exercise showed that this could potentially be a
key exercise in the PFPS rehabilitation. The double leg squat
with isometric hip adduction exercise will be useful in
restoring quadriceps strength with a desirable VMO activa-
tion when there is a large deficit in VMO muscle activity in
patients with PFPS.
This is the first study to look at the biomechanics of a lunge
exercise. The VMO:VL ratio of the lunge exercise was closest
to the idealized 1:1 ratio (24). Although this exercise has been
shown not to produce as much muscle activity as the double
leg squat with hip adduction exercise, this exercise may be
advantageous in the initial stage of PFPS rehabilitation when
sufficient VMO muscle strength has not been regained yet
and the priority is to establish a balanced patella tracking.
Little research has been undertaken regarding different stages
of rehabilitation; therefore, this is an area that warrants
further investigation.
Attempts were made to ensure rigorous and sound
methodology throughout the study. Exercises and electrode
placement were strictly standardized, and confounding vari-
ables (fatigue effect, skin impedance, and learning effect) were
TM

identified and accounted for in the study design, alongside
strict inclusion exclusion criteria, to maximize external
validity. There were a number of limitations within the study.
First, all the participants are asymptomatic and findings
therefore cannot be generalized to patients with PFPS. The
numerous independent variables that relate to musculoskel-
etal rehabilitation such as pain inhibition, secondary compli-
cations, previous functional level, and stage of rehabilitation
could potentially and significantly alter results. Future study
will therefore require the investigation of symptomatic
patients to enhance both the rigor and the external validity
of the research. Second, the protocols used for electrode
placement allowed for no variation in gender and size.
Therefore, it cannot be certain that we sampled fibers from
the correct muscles; however, this is a common flaw through-
out the literature (8). This is clinically significant because
recent research showed that EMG pads positioned at mid-
thigh level, opposed to closer to the muscles insertion,
detected lower signal strength owing to the close proximity
of EMG pads positioning at mid-thigh level than a lower
signal strength would be detected owing to its close
proximity to the muscle’s point of innervation (29). Finally,
the current study only examined the maximum EMG activity
for each exercise. Further study may wish to examine total
muscle activity during the exercise. In addition, comparing
concentric and eccentric phases of activity may provide
interesting results.
This study investigated the exercises with no external
additional weight. This ensured standardization and func-
tionality. However, it could be beneficial to study the effect of
external load on these specific VMO exercises because it is
common consensus that an external load will cause muscle
fatigue more rapidly than if no load was added. This in turn
may be of interest because knowledge of fatigue rates could
assist the practitioner in exercise prescription.
This research not only adds to the existing debate con-
cerning PFPS, but also highlights that there is a requirement
to investigate which exercise can preferentially alter the
VMO:VL ratio and how the muscles respond to overloading
and long-term rehabilitation. Fatigue has detrimental effects
on muscle performance; therefore, considering the specific
fatigue rates of VMO and VL is vitally important when
designing exercise protocols for patients with PFPS (22). No
research, as yet, has been undertaken to examine the fatigue
rates of the quadriceps using exercises that specifically target
VMO. Such knowledge would allow the development of
appropriate exercise protocols regarding number of repeti-
tions, load, and intensity. This study has been the first to
investigate the effects of the lunge exercise on VMO and VL
activity and is an area that requires further study in both
symptomatic and asymptomatic participants.
PRACTICAL APPLICATIONS
In summary, this study showed that double leg squat with
isometric hip adduction exercise produces significantly
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Journal of Strength and Conditioning Research | www.nsca-jscr.org
greater VMO activation than both the lunge exercise and
the open-chain knee extension exercise. Furthermore, the
double leg squat with isometric hip adduction exercise and
the lunge exercise produced a significantly higher VMO:VL
ratio than that of the open-chain leg extension exercise. In our
study, the open-chain knee extension exercise was shown to
preferentially activate VL instead of VMO and therefore may
not be suitable for patients with PFPS.
One of the main factors leading to patellofemoral pain is the
muscle imbalance between the VMO and VL, leading to an
excessive lateral tracking of the patella. Because the VMO and
VL demonstrated a lower level of activation during the lunge
exercise, the lunge exercise will be useful in the initial stage of
PFPS rehabilitation when sufficient VMO muscle strength
has not been regained yet and the priority is to establish
a balanced patella tracking. The higher muscle activity and
preferential VMO:VL ratio generated by the double leg squat
with isometric hip adduction exercise will be very useful in
further reestablishing the correct tracking of the patella and
strengthening of the VMO muscles in the later stage of PFPS
rehabilitation. The results of this study provide the scientific
basis for the use of the lunge exercise in devising a closed-
chain exercise protocol for VMO strengthening with a lunge
exercise potentially commencing rehabilitation and progress-
ing to a squat with isometric hip adductions as a later stage
addition. This research potentially assists the practitioner in
selecting the most appropriate exercises at the correct stage of
rehabilitation, thereby reducing the severity of PFPS and
decreasing rehabilitation times of patients with patella
maltracking. Further research is vital to distinguish the effects
of these exercises on symptomatic participants.
ACKNOWLEDGMENTS
No benefits in any form have been or will be received from
a commercial party/grant body related directly or indirectly
to the subject of this manuscript.
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