Biomechanical considerations in

patellofemoral joint rehabilitation

LISA A. STEINKAMP,*† MS, PT, MICHAEL F. DILLINGHAM,‡ MD,
MARK D. MARKEL,§ DVM, PhD, JENNIFER A. HILL,∥ AND
KENTON R. KAUFMAN,
a PhD

From *Functional Rehabilitation and Sports Therapy, Palo Alto, California, ‡Sports, Orthopedic
and Rehabilitation Medicine Associates, Portola Valley, California, the §Comparative
Orthopaedic Research Laboratory, Department of Surgical Sciences, School of Veterinary
Medicine, University of Wisconsin-Madison, Madison, Wisconsin, the ∥ Veteran’s Administration
Medical Center, Palo Alto, California, and the a
Children’s Hospital and Health Center, San
Diego, California

ABSTRACT function.4,12 Patellofemoral joint arthritis can originate from

Patellofemoral joint biomechanics during leg press and
leg extension exercises were compared in 20 normal
subjects (10 men, 10 women) aged 18 to 45 years.
Knee moment, patellofemoral joint reaction force, and
patellofemoral joint stress were calculated for each
subject at four knee flexion angles (0°, 30°, 60°, and
90°) during leg press and leg extension exercises.
All three parameters (knee moment, patellofemoral
joint reaction force, and patellofemoral joint stress)
were significantly greater in leg extension exercise than
leg press exercise at 0&deg; and 30&deg; of knee flexion (P <
0.001). At 60&deg; and 90&deg; of knee flexion, all three param-
eters were significantly greater in leg press exercise
than leg extension exercise (P < 0.001). Patellofemoral
joint stresses for leg press and leg extension exercises
intersected at 48&deg; of knee flexion.
This study demonstrates that patients with patello-
femoral joint arthritis may tolerate rehabilitation with leg
press exercise better than with leg extension exercise
in functional ranges of motion because of lower patel-
lofemoral joint stresses.
Patellofemoral joint disease is frequently encountered in
most orthopaedic medical practices. Although there are
many types of patellofemoral joint disease, patellofemoral
joint arthritis is a common cause of discomfort and decreased
t Address correspondence and reprint requests to: Lisa A. Steinkamp, MS,
PT, Functional Rehabilitation and Sports Therapy, 401 Lambert Avenue, Palo
Alto, CA 94306.
438
insults such as overuse, trauma, and malalignment, and can
be seen in patients of all ages, backgrounds, and activity
levels.4,12
Great controversy surrounds the proper rehabilitation of
patellofemoral joint arthritis, whether it is coincident with
surgical intervention or not. It has historically been assumed
that strong quadriceps lead to abated knee symptoms be-
cause of the quadriceps’ role in deceleration and concomitant
reduction in joint impact, 5,19.23 as well as their influence on
the anatomic position of the patella with respect to the
femur. 12,31
The most practical way to maximally strengthen the quad-
riceps appears to be with a leg extension maneuver since
this exercise allows for quadriceps isolation .2’ As technology
has advanced, different types of leg extension resistances
have evolved. These include isotonics with a weighted ankle
boot, 13,14,22,25,31 isotonics with resistance provided at a right
angle to the moment arm,zz,31 variable isotonics where the
inconsistent moment arm is taken into account,31 and iso-
kinetics where the resistance accommodates the abilities of
the muscle throughout the range of motion .21,31 Leg exten-
sions have been the traditional means of strengthening the
quadriceps to combat patellofemoral joint arthritiS24 ; how-
ever, we have found that this exercise exacerbates symptoms
of the disease in many patients.
A less prevalent approach to quadriceps strengthening has
been the leg press exercise. 24 The leg press is termed a closed
kinetic-chain exercise in which hip, knee, and ankle joints
work simultaneously and cocontractions exist between an-
tagonistic muscle groups.24,27 Although the quadriceps are
not isolated during a leg press motion, they participate in a
 439

more functional maneuver, simulating activities of daily

living and sports,ll,13,14,20,31 which subsequently encourages
normal neuromuscular integration. 1,24 Furthermore, it has
been our experience that patients with patellofemoral joint
arthritis have better tolerance for leg press exercise than for
leg extension exercise.
Therefore, the purpose of this study was to biomechani-
cally compare leg extension and leg press exercises in 20 where MK = knee moment, F weight of leg press, ~3
= =

normal subjects. Parameters evaluated included knee mo- incline of leg press (45°), Is length of shank, h length of
= =

ment, patellofemoral joint reaction (compressive) force, and

thigh, a knee flexion angle, W weight of shank and foot
= =

patellofemoral joint stress (compressive force per contact (6% of total body weight),’ and d distance from lower leg
=

area). center of mass to knee axis (43.4% of distance between knee

MATERIALS AND METHODS
Twenty normal subjects, aged 18 to 45 years, who were
trained in the exercises studied, participated in the study;
there were 10 men and 10 women. These subjects were
volunteers with no history of patellofemoral joint injury or
disease. Height, weight, length of thigh (hip joint center to
midpoint of the femoral condyles), length of shank (mid-
point of the femoral condyles to midpoint of the medial and
lateral malleoli), and length of the applied load moment arm
(midpoint of the femoral condyles to ankle dorsum) were
recorded for each subject.
axis and medial malleolus).3
The following assumptions were made:
1. The line joining the ankle joint center and hip joint
center was parallel to the incline of the leg press.
2. There was no friction on the bearings in the leg press.
3. The knee axis was unicentric.
4. The system was not moving, i.e., the contraction was
isometric.
From these calculations, the maximum knee moment for
each subject was determined (occurring at 90° of flexion in
all subjects).
Leg extension. Using the maximum knee moment calcu-
lated for each subject performing leg press exercise (obtained
at 90° of flexion), the weight required for leg extension

Knee moment
Leg press. The subjects were trained in the proper use of
the leg press. The maximum amount of weight with which
they could complete 3 sets of 10 repetitions on an inclined
leg press of 45° was determined. Corresponding hip angle
measurements were taken statically at 0°, 30°, 60°, and 90°
of knee flexion. All measurements were recorded 3 times per
subject.
Knee moment was calculated at the respective knee flex-
ion angles of 0°, 30°, 60°, and 90° using the following
equation (Fig. 1):
exercise to produce the equivalent maximum knee moment
(occurring at 0° of flexion in all subjects) was determined
using the following equation (Fig. 2):
where MK =
knee moment, W = weight of shank and foot
(6% of total body weight),’ d = distance from lower leg
center of mass to knee axis (43.4% of distance between knee
axis and medial malleolus),3F =
weight on leg extension, I
=
distance from knee center to leg extension weight, and a
=
knee flexion angle.
The following assumptions were made:
1. The knee axis was coincident with the rotation axis of
the leg extension machine.
2. The knee axis was unicentric.
3. The leg was not moving, i.e., the contraction was
isometric.
Once the weight value was determined that would produce
a maximum moment on the leg extension machine equiva-
lent to that on the leg press machine, knee moments at 30°,
60°, and 90° of flexion were calculated.

Quadriceps force
Quadriceps force was determined at 0°, 30°, 60°, and 90° of
knee flexion for both leg press and leg extension exercises
using the following equation (Fig. 3):
Figure 1. Leg press exercise. MK, knee moment; F, weight of
leg press; ~3, incline of leg press; IS, length of shank; h, length
of thigh; a, knee flexion angle; W, weight of shank and foot;
where MK =
knee moment, FQ =
quadriceps force, Meff =
d, distance from lower leg center of mass to knee axis.
440

Figure 3. Knee forces, actual moment arm, and patellofemoral

joint contact area. Fo, quadriceps force; FpL, patellar ligament
Figure 2. Leg extension exercise. MK, knee moment; W, force; FpF, patellofemoral joint reaction force; Mactg actual
moment arm; a, patellofemoral joint contact area.
weight of shank and foot; d, distance from lower leg center
of mass to knee axis; F, weight on leg extension;I, distance 4/30-569ax cm-2542
from knee center to leg extension weight; a, knee flexion
(0.5 at 0°; 0.81 at 30°; 0.99 at 60°; 0.97 at 90°),2s,2s FQ =

angle. quadriceps force.

effective moment arm,

Patellofemoral joint stress

Patellofemoral joint stress was determined at 0°, 30°, 60°,

and 90° of knee flexion for both leg press and leg extension
(3.0 cm at 0°; 4.1 cm at 30°; 2.8 cm at 60°; 2.0 cm at 90°),32 exercises using the following equation (Fig. 3):
Mact actual moment arm (perpendicular distance from the
=

central axis of the patellar ligament to the tibiofemoral

contact point) 3’ FPL =
patellar ligament force.
where FPF patellofemoral joint reaction force, a patel-
= =

Patellofemoral joint reaction force lofemoral joint contact area (1.5 cm’ at 0°; 3.1 cm’ at 30°;
3.9 cm’ at 60°; 4.1 cm’ at 90°).l0
Patellofemoral joint reaction force was determined at 0°,
30°, 60°, and 90° of knee flexion for both leg press and leg
Statistics
extension exercises using the following equation (Fig. 3):
Knee moments, patellofemoral joint reaction forces, and
patellofemoral joint stress values for leg press and leg exten-
where FPF =
patellofemoral joint reaction force, sion exercises were compared using repeated measures
analysis of variance (ANOVA), examining the effects of type
k =
constant for each angle = FPF of exercise, sex, and knee flexion angle. When ANOVA
FQ revealed significant differences, Tukey’s test was performed

to evaluate these differences. All differences were considered
significant at the 95% confidence interval (P < 0.05). Sta-
tistical analyses were performed using commercially avail-
able software (SAS Institute Inc., Cary, NC).
RESULTS
Knee moments
Knee moments for leg press exercise and leg extension
exercise intersected at 50.7° of knee flexion (Fig. 4). The
maximum knee moments occurred at 90° of flexion and
decreased consistently to 0° of flexion during leg press
exercise. During leg extension exercise, the maximum knee
moments occurred at 0° of flexion and declined to minimum
values at 90° of flexion. Knee moments were higher for men
than women at all knee flexion angles during both leg press
exercise (P < 0.001) (Table 1) and leg extension exercise (P
< 0.0005) (Table 2). At 0° and 30° of flexion, knee moments
were significantly greater in leg extension exercise than leg
press exercise (P < 0.001). At 60° and 90° of flexion, knee
moments were significantly greater in leg press exercise than
leg extension exercise (P < 0.001).
Patellofemoral joint reaction forces
Whereas patellofemoral joint reaction forces mirrored knee
moments during leg press exercise, no significant differences
were found between patellofemoral joint reaction forces at
Figure 4. Mean (± SD) of knee moment at four flexion angles.
441
0°, 30°, and 60° of knee flexion during leg extension exercise
(Fig. 5). From 0° to 46.1° of knee flexion, patellofemoral
joint reaction forces were greater during leg extension ex-
ercise than during leg press exercise. At knee flexion angles
over 46.1°, greater patellofemoral joint reaction forces oc-
curred during leg press exercise than during leg extension
exercise. Patellofemoral joint reaction forces were consist-
ently higher for men than women during both leg press
exercise (P < 0.001) (Table 1) and leg extension exercise (P
< 0.0005) (Table 2). At 0° and 30° of knee flexion, patello-
femoral joint reaction forces were significantly greater in leg
extension exercise than leg press exercise (P < 0.001). At
60° and 90° of knee flexion, patellofemoral joint reaction
forces were significantly greater in leg press exercise than
leg extension exercise (P < 0.001).
Patellofemoral joint stress values
Intersection of the patellofemoral joint stress curves for leg
0
press exercise and leg extension exercise occurred at 48.4°
of knee flexion (Fig. 6). Patellofemoral joint stress values
for leg press exercise peaked at 90° of knee flexion and were
least at 0° of knee flexion. Patellofemoral joint stress values
for leg extension exercise peaked at 0° of knee flexion and
were least at 90° of knee flexion. Respective patellofemoral
joint stress values were higher for men than women during
both leg press exercise (P < 0.001) (Table 1) and leg exten-
sion exercise (P < 0.0005) (Table 2). At 0° and 30° of knee
flexion, patellofemoral joint stress values were significantly
greater in leg extension exercise than leg press exercise (P
< 0.001). At 60° and 90° of knee flexion, patellofemoral joint
stress values were significantly greater in leg press exercise
than leg extension exercise (P < 0.001).
DISCUSSION
Knee moments, resultant patellofemoral joint reaction
forces, and most importantly, patellofemoral joint stress
values differed for leg press exercise when compared with
leg extension exercise, depending on the angle of knee flex-
ion. This is clinically relevant when one considers that the
functional range of motion for most activities of daily living,
as well as sports, is in the lower end of the knee flexion
range, and that strengthening with leg extensions in this
range of motion subjects the patellofemoral joint to a signif-
icant amount of stress.l1,13,14,20,24,25,31 In contrast, leg press
maneuvers place minimal stress on the patellofemoral joint
in the functional range of motion.l1,13, 14, 20, 25, 31 This conclu-
sion has been supported by our own empirical observations;
patellofemoral patients seem to tolerate leg press exercise
but tend to have increased symptoms during leg extension
exercise. Additionally, we have found that many patients
without initial patellofemoral problems often become symp-
tomatic after leg extension exercise.
Most studies on patellofemoral joint biomechanics have
used leg extensions to research the knee extensor mecha-
nism.2,7.15-17.21,26,28-30 These studies have been inconsistent
in their definitions, terminology, and designs, and have
442

TABLE 1
A comparison of men and women during leg press exercise

°
Men were significantly greater than women at all knee flexion angles (P < 0.001) for all parameters.

TABLE 2
A comparison of men and women during leg extension exercise

° Men were significantly greater than women at all knee flexion angles (P < 0.0005) and for all parameters.

Figure 6. Mean (± SD) of patellofemoral joint stress at four

flexionangles..
Figure 5. Mean (± SD) of patellofemoral joint reaction force z

at four flexion angles.


values differed for leg press exercise when compared with
leg extension exercise, depending on the angle of knee flex-
ion. This is clinically relevant when one considers that the
functional range of motion for most activities of daily living,
as well as sports, is in the lower end of the knee flexion
range, and that strengthening with leg extensions in this
range of motion subjects the patellofemoral joint to a signif-
icant amount of stress.11,13,14,20,24,25,31 In contrast, leg press
maneuvers place minimal stress on the patellofemoral joint
in the functional range of motion.l1,13,14,20,25,31 This conclu-
sion has been supported by our own empirical observations;
patellofemoral patients seem to tolerate leg press exercise
but tend to have increased symptoms during leg extension
exercise. Additionally, we have found that many patients
without initial patellofemoral problems often become symp-
tomatic after leg extension exercise.
Most studies on patellofemoral joint biomechanics have
used leg extensions to research the knee extensor mecha-
nism.2,7,15-17,21,26,28-30 These studies have been inconsistent
in their definitions, terminology, and designs, and have
created confusing discrepancies in the literature.14~20,25 As a
result, proper rehabilitation of the patellofemoral joint has
remained a controversial topic. Since it has been assumed
that quadriceps strength is inversely related to patellofem-
oral joint pain,19 clinical emphasis has continued to be placed
on attaining maximum quadriceps hypertrophy by isolating
the quadriceps with leg extensions.24
Leg press exercise may not isolate the quadriceps, but the
quadriceps can be strengthened just as effectively without
joint isolation,9 and leg press is a more functional maneuver,
simulating the majority of normal movement pat-
terns.l1,13,14,20,24,31 Several studies have advocated closed ki-
netic-chain exercise for the patellofemoral joint, but the
effective moment arm has not been routinely incorporated
into data calculations. 13,14,18,22,25 The advent of the effective
moment arm, which is defined as the actual moment arm
(the perpendicular distance from the central axis of the
patellar ligament to the tibiofemoral contact point) times
the ratio of patellar ligament force to quadriceps tendon
force,32 has yielded more precise measurements of patello-
femoral joint reaction forces and subsequent patellofemoral
joint stresses.11,20 Most of the studies using the effective
moment arm have, again, focused on leg extensions. 2,7,28-30,32
As we have illustrated, the effective moment arm has much
more influence on patellofemoral joint reaction forces during
leg extension exercise than during leg press exercise. This is
because of the fact that at low flexion angles, when knee
moments are highest for leg extensions, the effective mo-
ment arm is longest and can favorably lower the patellofem-
oral joint reaction force. In contrast, knee moments are
greatest at high flexion angles during leg presses, at which
time the effective moment arm is shortest and cannot ben-
eficially lower the patellofemoral joint reaction force.
Stress, or force per area, is crucial to consider when
investigating the patellofemoral joint. 6,8,10,13,14,18,20,25,29,31,32
With respect to patellofemoral joint rehabilitation, it has
been recognized that maximum patellofemoral compressive
443
(joint reaction) forces during leg press maneuvers occur
when the patellofemoral contact area is the greatest, whereas
maximum patellofemoral compressive forces during leg ex-
tension motions occur when the patellofemoral contact area
is the least.&dquo;, 13,14,20,24,25,3’ A comparison of our patellofemoral
joint reaction force and patellofemoral joint stress curves
for leg extension exercise reveals the enormous impact con-
tact area has on resulting joint stress. Even though maxi-
mum compressive forces are lower for leg extensions relative
to leg presses, mainly because of the effective moment arm,
stress values for leg extensions rise dramatically secondary
to these maximum compressive forces being applied over
such minimal contact areas. The result is contrasting patel-
lofemoral joint stress curves for leg presses and leg exten-
sions, with the respective minimum and maximum stress
values for the two exercises occurring at opposite ends of
the range of motion. For leg presses, compressive forces are
higher but are distributed over a larger contact area; for leg
extensions, compressive forces are lower but are distributed
over a smaller contact area. This, in turn, could explain why
patients with patellofemoral joint arthritis experience pain
during leg extensions; maximum joint stresses are occurring
as a result of the largest compressive forces being applied to
the smallest contact areas. Theoretically, emphasis should
be placed on strengthening in the lower knee flexion range
since this is the range of motion in which most activities are
performed; considerably less patellofemoral joint stress is
generated in this range during leg press exercise than during
leg extension exercise.
One of the limitations of this study is that we did not take
into consideration that since there is no patellofemoral
articulation from 10° of knee flexion to full extension, it is
generally safe to strengthen in this range with any type of
exercise 13,14, ~g° 31; therefore, our stress values in this range of
motion may be inaccurate. It is also interesting to note that
while we found knee moments, patellofemoral joint reaction
forces, and patellofemoral joint stresses to be lower in
women than in men, other studies have presented contra-
dictory findings; women experience higher compressive
forces and joint stresses than men because they have shorter
patellar tendon moment arms.2°~21 However, these studies
assume the same knee moments for both men and women.
Studies that acknowledge that the average woman produces
smaller knee moments than the average man agree with our
comparative values. 11 Although our patellofemoral joint con-
tact area data were derived from both men and women
subjects,&dquo; the effective moment arms,32 extensor force ra-
tios,28,29 and anatomic weights and distances3 originated
from male subjects. It would therefore be advantageous to
conduct a study using the appropriate data for men and
women. Additionally, individualized patellofemoral joint
contact areas would obviously grant more specific patello-
femoral joint stress values than the standardized contact
areas employed in this study. Finally, this study presents a
static biomechanic analysis of the patellofemoral joint dur-
ing leg press and leg extension exercises; it would be bene-
ficial to perform a similar analysis dynamically.
444
We have attempted to demonstrate why patients with
patellofemoral joint arthritis have more tolerance for
strengthening with a leg press apparatus than with a leg
extension device. In our clinical experience, these patients
have less pain and increased ability when performing leg
presses than when attempting leg extensions. The probable
reason for their increased tolerance is that in the most
functional range of motion, there is significantly less patel-
lofemoral joint stress generated during leg press exercise
than during leg extension exercise.
ACKNOWLEDGMENT
The authors thank Cynthia Moore for her assistance with
this project.
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