Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Skip to main content
Springer Nature Link
Log in

Basic biomechanic principles of knee instability

  • ACL Update: Objective Measures on Knee Instability (V Musahl, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Motion at the knee joint is a complex mechanical phenomenon. Stability is provided by a combination of static and dynamic structures that work in concert to prevent excessive movement or instability that is inherent in various knee injuries. The anterior cruciate ligament (ACL) is a main stabilizer of the knee, providing both translational and rotatory constraint. Despite the high volume of research directed at native ACL function, pathogenesis and surgical reconstruction of this structure, a gold standard for objective quantification of injury and subsequent repair, has not been demonstrated. Furthermore, recent studies have suggested that novel anatomic structures may play a significant role in knee stability. The use of biomechanical principles and testing techniques provides essential objective/quantitative information on the function of bone, ligaments, joint capsule, and other contributing soft tissues in response to various loading conditions. This review discusses the principles of biomechanics in relation to knee stability, with a focus on the objective quantification of knee stability, the individual contributions of specific knee structures to stability, and the most recent technological advances in the biomechanical evaluation of the knee joint.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Grood ES, Noyes FR: Diagnosis of knee ligament injuries: Biomechanical precepts. In: Feagin JA, editor. The Crucial Ligaments. New York, Churchill Livingston 1994:245–60.

  2. Kakarlapudi TK, Bickerstaff DR. Knee instability—isolated and complex. West J Med. 2001;174(4):266–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Gianotti SM et al. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport. 2009;12:622–7.

    Article  PubMed  Google Scholar 

  4. Ellison A, Berg E. Embryology, anatomy, and function of the anterior cruciate ligament. Orthop Clin North Am. 1985;16:3–14.

    CAS  PubMed  Google Scholar 

  5. Hospodar SJ, Miller MD. Controversies in ACL reconstruction: bone-patellar tendon-bone anterior cruciate ligament reconstruction remains the gold standard. Sports Med Arthrosc. 2009;17(4):242–6.

    Article  PubMed  Google Scholar 

  6. Bonin M, Amendola A, Bellemans J, Mc Donald S, Ménétrey J (eds), The Knee Joint: Surgical Techniques and Strategies, Springer-Verlag 2012 Print.

  7. Alter MJ: Science of flexibility. 3rd ed. Champaign, IL: Human Kinetics Publishers; 2004: 3–4.

  8. Musahl V et al. Rotatory knee laxity and the pivot shift. Knee Surg Sports Traumatol Arthrosc. 2012;20:601–2.

    Article  PubMed  Google Scholar 

  9. Eastlack ME, Axe MJ, Snyder-Mackler L. Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc. 1999;31(2):210–5.

    Article  CAS  PubMed  Google Scholar 

  10. Ayeni OR et al. Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):767–77.

    Article  PubMed  Google Scholar 

  11. Jonsson H, Riklund-Ahlström K, Lind J. Positive pivot shift after ACL reconstruction predicts later osteoarthrosis: 63 patients followed 5–9 years after surgery. Acta Orthop Scand. 2004;75(5):594–9.

    Article  PubMed  Google Scholar 

  12. Kocher MS et al. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32(3):629–34.

    Article  PubMed  Google Scholar 

  13. Grood ES, Suntay WJ. A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng. 1983;105(2):136–44.

    Article  CAS  PubMed  Google Scholar 

  14. Monaco E, Ferretti A, Labianca L, Maestri B, Speranza A, Kelly MJ, et al. Navigated knee kinematics after cutting of the ACL and its secondary restraint. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2012;20(5):870–7.

    Article  CAS  Google Scholar 

  15. Anderson CJ, Westerhaus BD, Pietrini SD, Ziegler CG, Wijdicks CA, Johansen S, et al. Kinematic impact of anteromedial and posterolateral bundle graft fixation angles on double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2010;38(8):1575–83.

    Article  PubMed  Google Scholar 

  16. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32(3):629–34.

    Article  PubMed  Google Scholar 

  17. Bedi A et al. Lateral compartment translation predicts the grade of pivot shift: a cadaveric and clinical analysis. Knee Surg Sports Traumatol Arthrosc. 2010;18:1269–76.

    Article  PubMed  Google Scholar 

  18. Lopomo N, Zaffagnini S, Amis AA. Quantifying the pivot shift test: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):767–83.

    Article  PubMed  Google Scholar 

  19. Musahl V, Voos J, O’Loughlin PF, Stueber V, Kendoff D, Pearle AD. Mechanized pivot shift test achieves greater accuracy than manual pivot shift test. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2010;18(9):1208–13.

    Article  Google Scholar 

  20. Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med. 2010;38(8):1591–7.

    Article  PubMed  Google Scholar 

  21. Markolf KL, Park S, Jackson SR, McAllister DR. Simulated pivot-shift testing with single and double-bundle anterior cruciate ligament reconstructions. J Bone Joint Surg Am Vol. 2008;90(8):1681–9.

    Article  Google Scholar 

  22. Debandi A, Maeyama A, Lu S, Hume C, Asai S, Goto B, et al. Biomechanical comparison of three anatomic ACL reconstructions in a porcine model. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2011;19(5):728–35.

    Article  Google Scholar 

  23. Musahl V, Burkart A, Debski RE, Van Scyoc A, Fu FH, Woo SL. Accuracy of anterior cruciate ligament tunnel placement with an active robotic system: a cadaveric study. Arthrosc: J Arthrosc Relat Surg: Off Publ Arthrosc Assoc North Am Int Arthrosc Assoc. 2002;18(9):968–73.

    Article  Google Scholar 

  24. Kanamori A, Zeminski J, Rudy TW, Li G, Fu FH, Woo SL. The effect of axial tibial torque on the function of the anterior cruciate ligament: a biomechanical study of a simulated pivot shift test. Arthrosc: J Arthrosc Relat Surg: Off Publ Arthrosc Assoc North Am Int Arthrosc Assoc. 2002;18(4):394–8.

    Article  Google Scholar 

  25. Voos JE, Musahl V, Maak TG, Wickiewicz TL, Pearle AD. Comparison of tunnel positions in single-bundle anterior cruciate ligament reconstructions using computer navigation. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2010;18(9):1282–9.

    Article  Google Scholar 

  26. Hoshino Y et al. In Vivo Measurement of the Pivot-Shift Test in the Anterior Cruciate Ligament–Deficient Knee Using an Electromagnetic Device. Am J Sports Med. 2007;35(7):1098–104.

    Article  PubMed  Google Scholar 

  27. Kopf S et al. A new quantitative method for pivot shift grading. Knee Surg Sports Traumatol Arthrosc. 2012;20:718–23.

    Article  CAS  PubMed  Google Scholar 

  28. Lopomo N et al. Quantitative assessment of pivot-shift using inertial sensors. Knee Surg Sports Traumatol Arthrosc. 2012;20:713–7.

    Article  PubMed  Google Scholar 

  29. Araujo PH et al. Comparison of three non-invasive quantitative measurement systems for the pivot shift test. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):692–7.

    Article  PubMed  Google Scholar 

  30. Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res. 1980;147:45–50.

    PubMed  Google Scholar 

  31. Fleming BC, Beynnon BD, Tohyama H, Johnson RJ, Nichols CE, Renstrom P, et al. Determination of a zero strain reference for the anteromedial band of the anterior cruciate ligament. J Orthop Res: Off Publ Orthop Res Soc. 1994;12(6):789–95.

    Article  CAS  Google Scholar 

  32. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am Vol. 1982;64(6):883–8.

    CAS  Google Scholar 

  33. Nakamura S, Kobayashi M, Asano T, Arai R, Nakagawa Y, Nakamura T. Image-matching technique can detect rotational and AP instabilities in chronic ACL-deficient knees. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2011;19 Suppl 1:S69–76.

    Article  Google Scholar 

  34. Lipke JM, Janecki CJ, Nelson CL, McLeod P, Thompson C, Thompson J, et al. The role of incompetence of the anterior cruciate and lateral ligaments in anterolateral and anteromedial instability. A biomechanical study of cadaver knees. J Bone Joint Surg Am Vol. 1981;63(6):954–60.

    CAS  Google Scholar 

  35. Markolf KL, Willems MJ, Jackson SR, Finerman GA. In situ calibration of miniature sensors implanted into the anterior cruciate ligament part II: force probe measurements. J Orthop Res: Off Publ Orthop Res Soc. 1998;16(4):464–71.

    Article  CAS  Google Scholar 

  36. Scanlan SF, Chaudhari AM, Dyrby CO, Andriacchi TP. Differences in tibial rotation during walking in ACL reconstructed and healthy contralateral knees. J Biomech. 2010;43(9):1817–22.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sudasna S, Harnsiriwattanagit K. The ligamentous structures of the posterolateral aspect of the knee. Bull Hosp Joint Dis Orthop Inst. 1990;50(1):35–40.

    CAS  Google Scholar 

  38. Ajuied A, Wong F, Smith C, Norris M, Earnshaw P, Back D, et al. Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis. Am J Sports Med. 2014;42(9):2242–52.

    Article  PubMed  Google Scholar 

  39. Tardy N, Marchand P, Kouyoumdjian P, Blin D, Demattei C, Asencio G. A preliminary in vivo assessment of anterior cruciate ligament-deficient knee kinematics with the KneeM device: a new method to assess rotatory laxity using open MRI. Orthop J Sports Med. 2014;13:2(3).

    Google Scholar 

  40. Hoshino Y et al. Quantitative evaluation of the pivot shift by image analysis using the iPad. Knee Surg Sports Traumatol Arthrosc. 2013;21:975–80.

    Article  PubMed  Google Scholar 

  41. Muller B, Hofbauer M, Rahnemai-Azar AA, Wolf M, Araki D, Hoshino Y, et al. Development of computer tablet software for clinical quantification of lateral knee compartment translation during the pivot shift test. Comput Methods Biomech Biomed Eng. 2016;19(2):217–28. This recent work reports the development of a computer tablet software to quantify anterior translation of the lateral knee compartment during the pivot shift test. The software is shown to provide reliable, objective, and quantitative data on translation of the lateral knee compartment during the pivot shift test and can be used without significant time delay in the clinical setting.

    Article  Google Scholar 

  42. Zaffagnini S et al. Inertial sensors to quantify the pivot shift test in the treatment of anterior cruciate ligament injury. Joints. 2014;2(3):124–9. This recent work highlights the development of inertial sensors in the objective measurement of knee instability. This research may allow for information regarding the clinical significance of an ACL-injury to be collected in real-time, as past studies have documented the correlation between high acceleration values and clinical grade of pivot shift exam.

    PubMed  PubMed Central  Google Scholar 

  43. Berruto M et al. Is triaxial accelerometer reliable in the evaluation and grading of knee pivot-shift phenomenon? Knee Surg Sports Traumatol Arthrosc. 2013;21:981–5.

    Article  CAS  PubMed  Google Scholar 

  44. Labbé DR, Li D, Grimard G, de Guise JA, Hagemeister N. Quantitative pivot shift assessment using combined inertial and magnetic sensing. Knee Surg Sports Traumatol Arthrosc. 2015;23(8):2330–8.

    Article  PubMed  Google Scholar 

  45. Matsumoto H. Mechanism of the pivot shift. J Bone Joint Surg (Br). 1990;72(5):816–21.

    CAS  Google Scholar 

  46. Lane CG et al. In vivo analysis of the pivot shift phenomenon during computer navigated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16(5):487–92.

    Article  PubMed  Google Scholar 

  47. Guenther D, Griffith C, Lesniak B, Lopomo N, Grassi A, Zaffagnini S, et al. Anterolateral rotatory instability of the knee. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2909–17.

    Article  PubMed  Google Scholar 

  48. Wroble RR, Grood ES, Cummings JS, Henderson JM, Noyes FR. The role of the lateral extraarticular restraints in the anterior cruciate ligament-deficient knee. Am J Sports Med. 1993;21(2):257–62. discussion 263.

    Article  CAS  PubMed  Google Scholar 

  49. Rasmussen MT, Nitri M, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF. An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 1: Secondary Role of the Anterolateral Ligament in the Setting of an Anterior Cruciate Ligament Injury. Am J Sports Med. 2016 Mar; 44(3):585-92.

  50. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159–72.

    CAS  PubMed  Google Scholar 

  51. Johnson LL. Lateral capsular ligament complex: anatomical and surgical considerations. Am J Sports Med. 1979;7(3):156–60.

    Article  CAS  PubMed  Google Scholar 

  52. LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997;25(4):433–8.

    Article  CAS  PubMed  Google Scholar 

  53. Woods GW, Stanley RF, Tullos HS. Lateral capsular sign: X-ray clue to a significant knee instability. Am J Sports Med. 1979;7(1):27–33.

    Article  CAS  PubMed  Google Scholar 

  54. Rudy TW, Livesay GA, Woo SL, Fu FH. A combined robotic/universal force sensor approach to determine in situ forces of knee ligaments. J Biomech. 1996;29(10):1357–60.

    Article  CAS  PubMed  Google Scholar 

  55. Suero EM, Njoku IU, Voigt MR, Lin J, Koenig D, Pearle AD. The role of the iliotibial band during the pivot shift test. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2013;21(9):2096–100.

    Article  Google Scholar 

  56. Yamamoto Y, Hsu WH, Fisk JA, Van Scyoc AH, Miura K, Woo SL. Effect of the iliotibial band on knee biomechanics during a simulated pivot shift test. J Orthop Res: Off Publ Orthop Res Soc. 2006;24(5):967–73.

    Article  Google Scholar 

  57. Kittl C, et al.: The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee, Am J Sports Med. 2015. This publication recently showed that the ‘anterolateral ligament’ and anterolateral capsule had a minor role in restraining internal rotation of knee, and therefore have a minimal role in the control of rotatory stability. The iliotibial tract was the primary restraint at 30° to 90° of flexion, and therefore should be the anatomic structure injured if an extra-articular repair is to be performed

  58. Matsumoto H. Mechanism of the pivot shift. J Bone Joint Surg Br Volume. 1990;72(5):816–21.

    CAS  Google Scholar 

  59. Stijak L, Bumbasirevic M, Radonjic V, Kadija M, Puskas L, Milovanovic D, Filipovic B (2014) Anatomic description of the anterolateral ligament of the knee. Knee Surg Sports Traumatol Arthrosc. 2014 Nov 8.

  60. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321–8.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Musahl V, Rahnemai-Azar AA, van Eck CF, Guenther D, Fu FH. Anterolateral ligament of the knee, fact or fiction? Knee Surg Sports Traumatol Arthrosc. 2016;24(1):2-3.

  62. Dombrowski ME, Costello JM, Ohashi B, Murawski CD, Rothrauff BB, Arilla FV, Friel NA, Fu FH, Debski RE, Musahl V. Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee. Knee Surg Sports Traumatol Arthrosc. 2015 Feb 4. This publication highlights the anatomical, histological and imaging characterization of the anterolateral knee structures. This paper provides strong objective evidence to the contrary of an anterolateral ligament structure that controls rotational stability of the knee

  63. Rahnemai-Azar AA, Miller RM, Guenther D, Fu FF, Lesniak B, Musahl V, Debski RE. Structural Properties of the Anterolateral Capsule and Iliotibial Band of the Knee. Podium Presented in Summer Biomechanics, Bioengineering, and Biotransport Conference in June 2015 Utah and in American Academy of Orthopaedic Surgeons meeting; Orlando, FL. 2016.

  64. Araujo PH et al. Individualized ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):1966–75.

    Article  PubMed  Google Scholar 

  65. Ahlden M, Araujo P, Hoshino Y, Samuelsson K, Middleton KK, Nagamune K, et al. Clinical grading of the pivot shift test correlates best with tibial acceleration. Knee Surg, Sports Traumatol, Arthrosc: Off J ESSKA. 2012;20(4):708–12.

    Article  Google Scholar 

  66. Ahmed AM, McLean C. In vitro measurement of the restraining role of the anterior cruciate ligament during walking and stair ascent. J Biomech Eng. 2002;124(6):768–79.

    Article  CAS  PubMed  Google Scholar 

  67. Giffin JR et al. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med. 2004;32(2):376–82.

    Article  PubMed  Google Scholar 

  68. Senişik S et al. Posterior tibial slope as a risk factor for anterior cruciate ligament rupture in soccer players. J Sports Sci Med. 2011;10(4):763–7.

    PubMed  PubMed Central  Google Scholar 

  69. Brandon ML et al. The association between posterior-inferior tibial slope and anterior cruciate ligament insufficiency. Arthroscopy. 2006;22(8):894–9.

    Article  PubMed  Google Scholar 

  70. Marouane H, Shirazi-Adl A, Hashemi J. Quantification of the role of tibial posterior slope in knee joint mechanics and ACL force in simulated gait. J Biomech. 2015;48(10):1899–905.

    Article  CAS  PubMed  Google Scholar 

  71. Alentorn-Geli E et al. Prevention of anterior cruciate ligament injuries in sports. Part I: systematic review of risk factors in male athletes. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):3–15.

    Article  PubMed  Google Scholar 

  72. Song GY, et al.: Risk Factors Associated With Grade 3 Pivot Shift After Acute Anterior Cruciate Ligament Injuries. Am J Sports Med. 2015 Nov 30.

  73. Nelitz M et al. Increasing posterior tibial slope does not raise anterior cruciate ligament strain but decreases tibial rotation ability. Clin Biomech (Bristol, Avon). 2013;28(3):285–90.

    Article  Google Scholar 

  74. Kim D, Asai S, Moon CW, Hwang SC, Lee S, Keklikci K, et al. Biomechanical evaluation of anatomic single- and double-bundle anterior cruciate ligament reconstruction techniques using the quadriceps tendon. Knee Surg Sports Traumatol Arthrosc. 2015;23(3):687–95.

    Article  PubMed  Google Scholar 

  75. Bell KM et al. Novel technique for evaluation of knee function continuously through the range of flexion. J Biomech. 2015;48(13):3737–40. This recent work highlights the importance of continuous assessment of knee motion during in vitro robotic testing. This manuscript shows that continuous monitoring allows for more data collection across the range of motion, potentially elucidating trends across small subdivisions of total motion that will engage different constraints and anatomical structures.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

    Jason P. Zlotnicki & Jan-Hendrik Naendrup

  2. Orthopaedic Robotics Laboratory, University of Pittsburgh, 408 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA, 15219, USA

    Jason P. Zlotnicki, Jan-Hendrik Naendrup, Gerald A. Ferrer & Richard E. Debski

  3. Department of Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA

    Gerald A. Ferrer & Richard E. Debski

Authors
  1. Jason P. Zlotnicki
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jan-Hendrik Naendrup
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gerald A. Ferrer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Richard E. Debski
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Richard E. Debski.

Ethics declarations

Conflict of interest

Jason P. Zlotnicki, Jan-Hendrik Naendrup, Gerald A. Ferrer, and Richard E. Debski declare that they have no conflict of interest.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on ACL Update: Objective Measures on Knee Instability

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zlotnicki, J.P., Naendrup, JH., Ferrer, G.A. et al. Basic biomechanic principles of knee instability. Curr Rev Musculoskelet Med 9, 114–122 (2016). https://doi.org/10.1007/s12178-016-9329-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-016-9329-8

Keywords

Search

Navigation