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THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 27, No. 4
© 1999 American Orthopaedic Society for Sports Medicine

Current Concepts
Biomechanics of Knee Ligaments
Savio L-Y. Woo,* PhD, Richard E. Debski, PhD, John D. Withrow, and Marsie A. Janaushek

From the University of Pittsburgh Medical Center, Musculoskeletal Research Center,

Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania

Biomechanics is the application of engineering principles afforded us the opportunity to examine joint kinematics
to the study of forces and motions of biologic systems. As and the contribution of ligaments without artificial
they relate to sports medicine, biomechanical studies are constraints.
designed to determine the magnitude and direction of
forces and moments of various tissues in and around a
diarthrodial joint, as well as to measure the corresponding JOINT KINEMATICS
joint kinematics. This information can then be used by Kinematics, as it relates to the human body, describes the
clinicians for the assessment of function of a normal or an motion of diarthrodial joints as well as locomotion and
injured joint and for planning the appropriate course of gait. An understanding of normal joint kinematics is im-
treatment. portant for comparison purposes during diagnosis of in-
This article will first address the functional aspect of jury and for evaluating the success of treatment protocols.
the knee joint, specifically the joint kinematics in multiple Clinical examination of an injured knee joint is performed
degrees of freedom, and it will describe the function of the by examining the motion of the knee and comparing this
individual components within the knee joint that enable motion with that of the noninjured, contralateral knee.
its motion. Finally, the basic mechanical properties of Excessive knee motion in a certain direction during exam-
these components, especially those of the tendons and ination may be an indication that a specific structure
ligaments, will also be described. Various soft tissue struc- within the knee has been damaged. However, it is impor-
tures in and around the knee joint have been studied tant to recognize that the knee does not move only in the
extensively; therefore, we will use these findings to illus- direction of the applied load; motion also occurs naturally
trate a number of biomechanical principles and concepts. in other translational and rotational directions.
Much of the knowledge gained through the study of the
knee joint can also be applied to other synovial joints of
the body, such as the shoulder, ankle, or wrist. A glossary Multiple Degrees of Freedom of Joint Motion
of the frequently used technical terms to describe the The movement of the knee joint is governed by its liga-
biomechanical properties of tissues, adapted from the ments, other supporting soft tissue structures, and the
AAOS Orthopaedic Basic Science book,53 is provided in geometric constraints of the articular surfaces. The knee
Appendix 1 at the end of this paper. is capable of movement in six degrees of freedom: three
The determination of mechanical properties of liga- rotations and three translations. The description of knee
ments and tendons has been challenging because of the motion can be accomplished by relating movement to
many biologic and experimental testing factors; these fac- three principle axes: the tibial shaft axis, the epicondylar
tors contribute to the wide spectrum of published tensile axis, and the anteroposterior axis, which is perpendicular
property data. In recent years, advanced technology has to the other axes (Fig. 1).30 Translations along these axes
become available that allows for more refined experimen- are referred to as proximal-distal, medial-lateral, and an-
tal procedures, enabling more accurate and reliable data terior-posterior translation, respectively. Rotations about
collection. Specifically, the use of robotic technology has these axes are referred to as internal-external rotation,
flexion-extension, and varus-valgus rotation, respectively.
Early laboratory studies on knee motion frequently lim-
* Address correspondence and reprint requests to Savio L-Y. Woo, PhD, ited joint motion to a single degree of freedom. The results
Musculoskeletal Research Center, Department of Orthopaedic Surgery, Uni- of these studies were reported as changes in knee kine-
versity of Pittsburgh, POB 71199, Pittsburgh, PA 15213.
No author or affiliated institution has received financial benefit from re- matics, in one degree of freedom, in response to an applied
search in this study. load. For example, anterior tibial translation in response

533
534 Woo et al. American Journal of Sports Medicine

Figure 2. Schematic diagram of the robotic/UFS testing sys-

tem with a knee specimen in place.
Figure 1. Schematic diagram illustrating the six degrees of
motion of the human knee joint. (Reproduced with permis-
sion from Woo SL-Y, Livesay GA, Smith: Kinematics, in Fu
system can operate under position control by moving the
FH, Harner CD, Vince KG (eds): Knee Surgery. Baltimore,
specimen along a previously recorded motion path and the
Williams & Wilkins, 1994, pp 155–173.)
UFS records a new set of force and moment data. This
allows measurement of the in situ forces in various soft
to an anterior tibial load was measured while constraining tissue structures using the principle of superposition (the
other degrees of freedom (such as medial-lateral transla- vector difference in forces measured before and after the
tion and internal-external rotation). Tests conducted in sectioning of a ligament can be attributed to the ligament
this manner yield knee kinematic data under artificially because identical knee motions are repeated).25, 52
constrained conditions that do not necessarily represent
the in vivo kinematics of the knee. One example of limi-
tations imposed by constraining degrees of freedom is
varus-valgus stress testing of the knee at various flexion Normal Versus Injured Knee Joint
angles. When knee motion is limited to three degrees of The overall motion of the knee is controlled by interactions
freedom (varus-valgus rotation, proximal-distal and medi- between its many supporting structures. If any one struc-
al-lateral translation), varus-valgus stability is increased ture is damaged, the overall motion of the knee will likely
and the medial collateral ligament is the primary re- be altered. Complete disruption of a ligament may lead to
straint for resisting valgus moments applied to the tibia.38
symptoms of knee instability. The resulting, altered mo-
However, when the knee is less constrained (allowing
tion of the knee may injure other structures, especially the
anteroposterior translation and internal-external tibial
menisci and the articular cartilage. Specific clinical exam-
rotation), knee stability is reduced and the ACL becomes
inations such as the anterior drawer test, Lachman test,
the dominant ligament for resisting valgus knee motion.
and pivot-shift test are performed to assess ligament in-
This result is observed because the ACL controls coupled
tegrity. These tests are performed at given knee flexion
anteroposterior translations and axial tibial rotations to a
greater degree than does the medial collateral ligament. angles and allow the tibia to displace anteriorly and also
Therefore, if one is interested in studying normal knee to rotate internally, producing five degrees of freedom
kinematics, a five degrees of freedom valgus stress test motion.28 In the intact knee, anterior tibial translation of
should be performed. In contrast, if one is interested in 3 to 5 mm is considered normal during an anterior drawer
studying the function of the medial collateral ligament, a or Lachman test. In an ACL-deficient knee, anterior
three degrees of freedom valgus test would be appropriate. translation and internal rotation of the tibia are increased
Multiple degrees of freedom experiments have been per- to varying degrees. In this scenario, other structures are
formed by our research group using a robotic/universal recruited to resist the abnormal joint motion that is
force-moment sensor (UFS) testing system (Fig. 2). This present in the ACL-deficient knee. From this information,
system can operate in both force and position control. one can see that normal function of the knee involves
While operating in force control, the robot applies a pre- many soft tissue structures, and when a single ligament is
determined external load to the specimen and the corre- disrupted, the remaining structures compensate by carry-
sponding five degrees of freedom kinematics of the speci- ing increased loads. The increased demand placed on the
men are recorded. Alternatively, the robotic/UFS testing structures may render them more susceptible to injury.
Vol. 27, No. 4, 1999 Biomechanics of Knee Ligaments 535

CONTRIBUTION OF INDIVIDUAL STRUCTURES mechanical contact between the device and the liga-
ment.27, 35, 36, 56 In our research center, in situ forces in the
The primary role of the ligaments surrounding the knee is ACL were determined by combining ligament length data
to provide stability to the joint throughout its range of obtained from a six degrees of freedom kinematic linkage
motion. Each ligament plays a role in providing stability system with its load-elongation data. Under the applica-
in more than one degree of freedom as well as restraining tion of a 6100 N external anteroposterior load, the length
knee motion in response to externally applied loads. Over- of the entire ACL, as well as the anterior portion of the
all joint stability depends on the contributions of the in- ACL, were determined. Subsequently, the load-length
dividual ligaments as well as the interaction between curve for the same portions of the ACL during tensile tests
ligaments. Knowledge of the in situ forces in the ligaments were determined.55 With these two sets of data, the in situ
during normal knee function contributes to our under- forces in the ACL in response to the anteroposterior load
standing of injury mechanisms and aids in the develop- were determined. It should be noted that this is an indi-
ment of rehabilitation protocols after knee injury. rect approach and requires an assumption of the direction
of force in the ACL.
Determination of In Situ Forces in the Ligaments Another noncontact method involves the use of the UFS,
which measures three forces and three moments along
Recently, many devices have been used to measure the and about a Cartesian coordinate system fixed with re-
force in ligaments, including both contact and noncontact spect to the sensor.26 For a rigid body attached to the UFS,
methods. Contact methods include devices that are at- the three forces collected by the sensor can be used to
tached to the ligament (for example, the buckle transduc- determine the magnitude and direction of an external
er),3, 4, 6, 10, 40, 41 implantable force transducer, modified force applied to the body. The point of application of the
pressure probe, and various strain gauges. With buckle force can also be determined based on evaluation of the
transducers, the ligament is passed through a “buckle,” three moments recorded.
which deflects when the tension in the ligament increases. Recently, we have used a UFS in combination with a
The deflected beam transducer (or implantable force robotic manipulator to develop a testing system that can
transducer) and the implantable pressure transducer (or directly determine the in situ forces in ligaments without
modified pressure probe) are similar to the buckle trans- contact with the tissue or dissection of the joint. This
ducer, but must be implanted in the ligamentous tis- technology has led to accurate simulation of multiple de-
sue.29, 34 These devices work on the concept that increases grees of freedom joint motion and enables the determina-
in ligament tension will increase the transverse force on tion of the in situ forces in individual soft tissue structures
the implanted device. The force in the ligament is then in and around the joint in response to external loading
determined during posttest calibration in which a relation conditions. Additionally, the robotic/UFS testing system
between the deflection of the device and the force in the allows researchers to apply multiple and combined load-
ligament is established. ing conditions to the same knee specimen, thus eliminat-
Devices attached to the subchondral bone beneath the ing interspecimen variability. Furthermore, the robotic/
ACL for direct measurement of in situ forces have also UFS testing system can provide a quantitative comparison
been used.20, 33 One study used a load cell attached to the of in situ forces in intact ligaments with those in replace-
tibial insertion of the ACL for measurement of the result- ment grafts. This enables investigators to determine the
ant forces in the ligament during testing.42, 43 The ACL efficacy of reconstruction in reproducing normal force
was found to be loaded under both internal and external transmission through the replacement graft. The next
tibial rotation between full extension and 45° of flexion. section will illustrate the potential of this testing system.
An internal tibial torque of 10 Nzm produced a force on the
order of 100 N in the ACL at 20° of flexion, while an Individual Ligament Function: Effect of Constraints
external tibial torque of 10 Nzm produced a smaller force
on the order of 50 N. Changes in ligament forces were also Using the robotic/UFS testing system, it is possible to
determined after the sectioning of the posterolateral assess the five degrees of freedom joint kinematics and
structures. The force in the PCL increased after postero- determine the in situ forces in the knee ligaments.24, 52
lateral-structure sectioning under an applied external The robotic/UFS testing system is advantageous because
torque, whereas the force in the ACL decreased. As will be it has a high degree of repeatability for position, orienta-
illustrated later, the resultant measurement of ligament tion, and load application. Additionally, it is capable of
in situ force for constrained (limiting the degrees of free- producing loads similar to those used during clinical ex-
dom) versus unconstrained motion (where multiple de- aminations.17 The robotic manipulator can “learn” the
grees of freedom motion is allowed) is significantly differ- complex motion of a knee specimen in response to external
ent. Thus, it is difficult to compare results between loads and reproduce these motions after the specimen has
different studies because the number of degrees of free- been modified (that is, after transecting a ligament or
dom used during testing has a significant effect on the reconstructing an injured ligament). The UFS simulta-
resultant kinematics. neously records the forces and moments acting on the
When using noncontact methods for determining the in knee while the knee is being moved by the robot.
situ forces in a ligament, a device is used that avoids the This testing system has been used to study the effect of
potential alteration of the ligament response induced by constraint conditions on knee kinematics and the in situ
536 Woo et al. American Journal of Sports Medicine

force in the ACL in response to an externally applied load.

Anteroposterior tibial loads were applied to the same knee
when it was in an unconstrained (five degrees of freedom)
and a constrained (one degree of freedom, anteroposterior
translation only) condition (Fig. 3). For the unconstrained
case, the anterior tibial load resulted in anterior tibial
translation that was 1.3 to 1.4 times greater than the
translation observed in the constrained knee from 30° to
90°. Although the magnitude of the in situ force did not
differ significantly between the constrained and uncon-
strained cases (Fig. 4), the direction of the in situ force did
differ significantly (Fig. 5). In the unconstrained case, the
force was directed more parallel to the tibial plateau.
Constrained knee motion also caused a shift in the force
sharing between the anteromedial and posterolateral Figure 4. Graph depicting the percent of the in situ force in
bundles of the ACL. Thus, constraints placed on the mo- the ACL supported by the anteromedial bundle under 100 N
tion of the knee will yield very different results. The di- anterior tibial loading (N 5 8; mean plus or minus SD).
rection of the force vector and distribution of in situ forces
within the ACL provide important functional information.
Therefore, it is clear that, during experiments, the knee
joint must be allowed multiple degrees of freedom motion
to accommodate the complexity of the knee.

TENSILE PROPERTIES OF LIGAMENTS

Knowing that the ligaments are essential elements for
proper knee function, it is necessary to characterize their
biomechanical properties, that is, the relation between
length and tension. A uniaxial tensile test is generally
employed to obtain fundamental ligament properties. Figure 5. Schematic diagrams showing the direction of the
in situ forces the ACL for a right knee at 30° of knee flexion,
under a 100-N anterior tibial load.

These properties are valuable for our understanding liga-

ment function and for evaluating which types of graft
material would be best suited for their replacement. Be-
cause ligaments are usually short, the bone-ligament-bone
complex is normally tested as a functional unit. However,
testing the entire complex makes it difficult to distinguish
between elongations of the midsubstance and those of the
bony insertions. With the advent of video systems, a
method has been developed for tensile testing whereby
both the structural properties of the bone-ligament-bone
complex and the mechanical properties of the ligament
substance are obtained simultaneously.60

Basic Anatomy

Ligaments are composed of water and densely packed

collagen fibers that run in the longitudinal direction, par-
allel to the axis of loading. The collagen is primarily type
I (approximately 70% fat-free dry weight), with a small
amount of type III (3% to 10% fat-free dry weight) and
trace amounts of types V, X, XII, and XIV collagen. Non-
Figure 3. Schematic diagrams detailing the joint motions collagenous proteins such as elastin, a fibrillar protein
allowed during unconstrained and constrained test condi- (less than 1%), and proteoglycans are also present. Water
tions. V-V, varus-valgus; A-P, anterior-posterior; M-L, medi- and proteoglycans provide lubrication and spacing, which
al-lateral; I-E, internal-external; P-D, proximal-distal. are critical to the gliding function of a joint.
Vol. 27, No. 4, 1999 Biomechanics of Knee Ligaments 537

The insertions of tendons and ligaments into bone are ness of the ligament increases to restrict any excessive
functionally adapted to dissipate forces through the tran- motion in the joint. However, if the applied load exceeds
sition from soft tissues to bone70; insertions are classified the maximum limits of the ligament, as may occur during
as either direct or indirect. Direct insertions consist of four athletic events, the risk of ligament damage increases.
morphologic zones: tendon, fibrocartilage, mineralized fi-
brocartilage, and bone (Fig. 6). Indirect insertions consist Structural Properties of Bone-Ligament-Bone Complex
of a superficial layer, which connects directly with the
periosteum, with deeper layers that anchor to the bone via Load-Elongation Curve. The structural properties that
Sharpey’s fibers. A ligament that exhibits both types of characterize the behavior of the bone-ligament-bone com-
insertions is the medial collateral ligament; it has a direct plex are represented by a load-elongation curve obtained
femoral insertion and an indirect tibial insertion. from a uniaxial tensile test. These properties depend on
Collagen fibrils in ligaments are arranged in varying the geometry of the ligament in addition to the properties
degrees of crimp such that an increase in tensile force of the bony insertion sites. During tensile testing of the
results in the recruitment of more fibrils to help resist the bone-ligament-bone complex, load is measured simulta-
increased load. The crimped nature of the fibrils serves to neously with the corresponding elongation. By plotting
guide joint motion and provide restraint at extremes of elongation as the independent variable, and load as the
joint motion. When a ligament is loaded in tension, it dependent variable, a load-elongation curve is obtained
responds by elongating. During normal activity, ligaments (Fig. 7). This curve can be divided into several regions.
are easily elongated to maintain normal kinematics and The first region, or the toe region, has a low initial stiff-
allow the joint to move easily and smoothly. With higher ness and is nonlinear. During activity, the crimped colla-
externally applied loads, such as during exercise, the stiff- gen fibers are easily extended and small initial forces
produce large elongations. Next, there is a linear region
with a higher stiffness (the slope of the curve), which
results from the fibers being stretched. Finally, the curve
reaches the ultimate load that the structure can with-
stand. On additional loading, failure of the bone-ligament-
bone complex occurs. The selected parameters used to
represent the structural properties of the bone-ligament-
bone complex are the linear stiffness (measured in new-
tons per millimeter), ultimate load (measured in newtons),
ultimate elongation (measured in millimeters), and en-
ergy absorbed at failure (measured in newton-millimeters,
and calculated by determining the area under the entire
load-elongation curve) (Fig. 7).

Mechanical Properties of the Ligament Substance

Mechanical properties characterize the behavior of the

ligament substance and are represented by a stress-strain
curve. These properties depend on the collagen composi-
tion, fiber orientation, and the interaction between colla-
gen and the ground substance.
Determination of Strain. Strain (e) is defined as the

Figure 6. Top, a direct insertion with its four morphologic

zones: tendon (T), uncalcified fibrocartilage (UF), calcified
cartilage (CF), and bone (B). Bottom, an indirect insertion
where the deep fibers of the ligament (L) pass into bone
through a well-defined zone of fibrocartilage (F). The arrow
represents the line of calcification. Figure 7. A schematic load-elongation curve for ligament.
538 Woo et al. American Journal of Sports Medicine

deformation per unit length of a ligament and can be midsubstance strain is measured while simultaneous
found by placing markers on the soft tissue in the region to load-elongation behavior is recorded. Using the load data,
be studied (such as midsubstance). Strain is calculated by along with the cross-sectional area measurement of the
the formula e 5 (l 2 lo)/lo; where lo represents the initial ligament, stress can be calculated. The stress-strain curve
distance between the markers and l is the length after a for a ligament is nonlinear (Fig. 8) and can be divided into
load is applied. Strain has no units but is usually ex- several regions. The first region is the nonlinear toe re-
pressed as a percent. gion. The second region is linear; the stress is linearly
Strain in ligaments has been measured by a wide vari- proportional to the strain and the slope of this region is
ety of devices including liquid mercury strain gaug- called the Young’s (or tangent) modulus (E, measured in
es,2, 11, 19, 39, 45 Hall-effect strain transducers (Microstrain, megapascals). Physically, a higher modulus can have sev-
Inc., Burlington, Vermont),8, 9, 12, 22, 23, 50 and the differen- eral different meanings: the ligament is made of a stiffer
tial-variable-reluctance-transducer (Microstrain). These material, there is more collagen per unit area, or its col-
devices are attached to the tendon or ligament along the lagen fibrils have larger diameters. Other important pa-
direction of the soft tissue. Noncontact methods have also rameters obtained from this curve are the ultimate stress
been developed to measure strains. The video dimension (or sometimes called the tensile strength, measured in
analyzer system60, 68 and the Motion Analysis System megapascals), ultimate strain, and the strain energy den-
(Motion Analysis Corporation, Santa Rosa, California) sity (measured in megapascals). The ultimate stress, ulti-
both use a video camera and an image-processing system. mate strain, and strain energy density are properties of
All of these techniques have the advantage of measuring the ligamentous tissue and therefore can only be deter-
midsubstance strain independently of strain at the inser- mined if failure occurs within the substance of the tissue.
tion sites. In addition, noncontact techniques do not re- For this reason, it is also important to know the mode of
quire mechanical or physical attachments onto the soft failure of the specimen.
tissue substance when the strains are measured.
Determination of Stress. Stress (measured in newtons Time- and History-Dependent Behavior: Viscoelasticity
per square millimeter) is defined as the load per unit
cross-sectional area of a ligament. It can be calculated Ligaments also display time- and history-dependent vis-
by the formula: s 5 F / A where s is stress, F is the coelastic properties.15 These properties include creep (an
externally applied load, and A is the cross-sectional increase in the length over time under a constant load),
area of the ligament. Because stress is defined as the stress-relaxation (a decrease in the load when the liga-
tensile load per cross-sectional area, an accurate meas- ment is held at a fixed elongation), and hysteresis (energy
ure of cross-sectional area is necessary. The earliest dissipation with continual loading and unloading) when
biomechanical studies used gravimetric methods in which subjected to a cycle of loading and unloading. Stretching
the volume of water displaced by a specimen could be or prolonged activity may cause a gradual creep of the
related to cross-sectional area by assuming a simple cross- ligaments that results in increasing knee laxity after
sectional shape.1, 44 Mechanical devices like calipers have exercise. However, after a period of rest, the ligaments
also been used to measure the width and thickness of a can recover and return to their original resting length,
specimen, with the cross-sectional area obtained by as- while the knee also returns to its original stiffness. Con-
suming a rectangular or elliptical shape.58 These methods versely, cyclic loading and unloading results in a corre-
are adequate for simple geometric structures, but may sponding cyclic stress relaxation, as the ligament is expe-
introduce large errors for ligaments that have more com- riencing a continuous decrease in stress with increasing
plex geometries. cycles. This behavior may serve as a mechanism for pro-
Noncontact methods have been developed that have the
advantages of avoiding tissue deformation and providing
more accurate cross-sectional area measurements for
more complex geometries. These methods involve an opti-
cal system (either visible or laser light) for measurement,
or an image-reconstruction technique to determine the
cross-sectional area or shape, or both.37 Examples of non-
contact approaches include the shadow amplitude meth-
od21 and the profile method.31 Another method uses a
laser micrometer system that casts a band of laser light
across a ligament that is rotating, allowing diameter read-
ings from all directions.58 Recently, a laser reflectance
system that can account for concavities in the tissue has
been developed.14 These laser methods perform much bet-
ter than contact methods for measurement of complex
geometries. In addition to accurate cross-sectional area
readings, they allow for graphic representation of the lig-
ament’s profile. Figure 8. A schematic stress-strain curve resulting from ten-
Stress-Strain Curve. During a uniaxial tensile test, the sile testing of a ligament.
Vol. 27, No. 4, 1999 Biomechanics of Knee Ligaments 539

tecting the ligament from fatigue failure. The unloading with another difficult. Some of these factors are identified
path of the load-elongation curve does not follow the same and are discussed in the next section to help the readers
path as the loading portion, known as the hysteresis ef- identify the effects of these factors on the mechanical
fect, indicating energy dissipation (Fig. 9). The peak load properties of ligaments.
decreases with an increasing number of cycles (that is,
stress relaxation); however, after a number of cycles the Biologic Factors
loading and unloading curves become repeatable, indicat-
ing the importance of preconditioning before experimental The biomechanical properties of ligaments and tendons
testing. depend on several biologic factors. For example, differ-
Examples demonstrating the importance of viscoelastic ences in specimen age, species, skeletal maturation, ana-
properties of ligaments are numerous. During ACL recon- tomic location, as well as exercise or immobilization can
struction, the initial force applied to tension the graft affect the properties of these tissues.
decreases over time as a result of stress relaxation. This Effects of Maturation and Age. Skeletal maturation has
effect has also been demonstrated in the primate patellar significant effects on the biomechanical properties of lig-
tendon where the stress in the tendon was reduced to aments and tendons. In general, these properties seem to
69.8% of the initial stress within 30 minutes.13 However, improve once skeletal maturity is reached. Several studies
preconditioning the graft can reduce the amount of stress performed on the rat tail tendon have shown an increase
relaxation by approximately 50% when compared with in collagen fibril size, ultimate load, and ultimate tensile
nonpreconditioning. These viscoelastic properties can also strength as the animal ages from puberty to adult-
be used to the surgeon’s advantage during intraoperative hood32, 46, 48 with no further changes observed until senes-
spinal distraction. By applying the distraction in small cence. Similarly, rapid increases in the cross-sectional
steps separated by a few minutes, the peak forces applied area, stiffness, and ultimate load of the rabbit medial
to the instrumentation and its insertions on the vertebra collateral ligament were found with maturation.66, 68 In
can be reduced over 50% because of vertebral soft tissue addition to changing mechanical properties during matu-
creep.47 ration, the mode of failure of the femur-medial collateral
ligament-tibia complex (FMTC) also changes. In younger
animals, where the epiphyses are not yet closed, the mech-
FACTORS AFFECTING THE MECHANICAL anism of failure is most often tibial avulsion. However, in
PROPERTIES OF LIGAMENTS skeletally mature animals in which the epiphyses are
Although much work has been done to determine the closed, ligaments are more likely to fail at the
mechanical properties of ligaments, the biologic and ex- midsubstance.66
perimental testing factors have contributed to differences In recent studies on the human femur-ACL-tibia com-
in reported results, making comparison of one set of data plex (FATC), values of structural properties from young
human donors have been significantly higher than those
from older donors. The stiffness and ultimate load for the
young ACL specimens (from donors aged 22 to 35 years)
were upwards of three times as high as those for older
specimens, and reported to be 242 6 28 N/mm and 2160 6
157 N, respectively.49, 62 The properties obtained for fe-
mur-ACL-tibia complexes from young donors should be
used as the strength requirements for ACL grafts used for
reconstructions.
Effect of Exercise. Recent research has suggested that
an increase in physical activity could improve the biome-
chanical properties of the medial collateral ligament.
Short-term exercise regimens, ranging from treadmill
walking to running and swimming, have been studied
using various animal models. The tensile properties of
swine femur-medial collateral ligament-tibia complexes
were assessed after 12 months of exercise59; some in-
creases in the structural properties of these complexes
were observed. When normalized to body weight, the ul-
timate load and linear stiffness increased 38% and 14%,
respectively, compared with the complexes of the seden-
tary controls. The mechanical properties also showed a
Figure 9. An example of a hysteresis curve. Typical loading minimal change with an increase in tensile strength and
(up arrow) and unloading (down arrow) curves from cyclic ultimate strain of 20% and 10%, respectively.
loading of soft tissue. The shaded area between the curves, Effect of Immobilization/Remobilization. After muscu-
called the area of hysteresis, represents the energy losses loskeletal injuries, immobilization is often used to protect
within the tissue. damaged tissue from further harm during the early stages
540 Woo et al. American Journal of Sports Medicine

of healing. However, the effect of joint immobilization can on rabbit femur-ACL-tibia complexes demonstrated that
have profound, adverse effects on the joint. Joint stiffness structural properties obtained from loading along the tib-
as a result of synovial adhesions and proliferation of fibro- ial axis varied with knee flexion angle. However, for spec-
fatty connective tissue has been observed both clinically imens loaded along the axis of the ligament, the structural
and experimentally after immobilization.5, 65 properties were independent of knee flexion.63
The effects of joint immobilization and remobilization Effect of Temperature. Studies have been performed to
on ligament properties on the rabbit medial collateral evaluate the relationship between temperature and ten-
ligament have also been studied in our research center.61 sile properties of ligaments, but these studies have yielded
Tensile testing of rabbit femur-medial collateral ligament- varying results. One study found no significant differences
tibia complexes was performed after 9 and 12 weeks of in mechanical properties of ligaments over a temperature
immobilization, in addition to 9 weeks of immobilization range of 0° to 37°C,51 while others have reported a decline
followed by 9 weeks of remobilization. The 9- and 12-week in elastic modulus and stiffness with increasing tempera-
immobilized groups had ultimate loads (tensile load re- ture.7 Studies in our laboratory on canine femur-medial
quired for failure) that were 31% and 29% of the contralat- collateral ligament-tibia complexes have revealed that lig-
eral controls, respectively (P , 0.01). The elastic modulus aments do exhibit temperature-dependent viscoelastic
of the medial collateral ligament also decreased after im- properties. Each canine femur-medial collateral ligament-
mobilization. In the remobilized group, the mechanical tibia complex was tested by cyclic loading in a saline bath
properties returned nearly to those levels of the control at varying temperatures from 2° to 37°C.64 These tests
group; however the structural properties remained infe- revealed an inverse relationship between stiffness and
rior to those of the controls. temperature, and also showed that the ligament relaxed
to lower values under cyclic loading performed at higher
Experimental Testing Factors temperatures.
Strain Rate. The influence of strain rate on injury is a
Several known experimental factors can also affect the debated topic. Sports-related injuries are estimated to oc-
determination of biomechanical properties of ligaments cur at strain rates that vary from relatively slow rates to
and tendons. Some factors such as the direction of the rates as high as 500 percent per second.16 Although inju-
applied external load and temperature of the specimen ries to ligaments often result at high strain rates, many
during testing will have an effect on these properties, experimental studies have examined the ligament proper-
while strain rate and proper specimen storage will not. ties under low-to-medium rates of strain because of the
Specimen Orientation. The medial collateral ligament is limitations of testing approaches and data collection sys-
an extraarticular ligament with a relatively simple geom- tems. However, data from recent studies suggest that the
etry and is oriented such that simultaneous loading of all effects of strain rate are overestimated, especially when
ligament fibers is possible. However, most bone-ligament- comparing strain rates such as 1 versus 100 percent per
bone complexes are nonuniform in geometry and shape; second. In fact, the status of the insertions, not the strain
therefore, the direction of applied force and the initial rate, may be the primary factor in determining the type of
position of the ligament are both important for accurate injury to the bone-ligament-bone complex.
assessment of load-elongation behavior. This is especially The effect of strain rates has been studied in medial
true for the ACL, which has a complex geometry and a collateral ligaments from skeletally mature rabbits using
nonuniform arrangement of the fiber bundles, making elongation rates over 4.5 decades, ranging from 0.008 to
uniform loading of the entire ligament impossible. Thus, 113 mm/s, corresponding to strain rates of the medial
the structural properties of the femur-ACL-tibia complex collateral ligament midsubstance of 0.01 to 200 percent
depend largely on the direction of applied load and initial per second.69 The structural properties of the femur-me-
orientation of the ligament during testing. Force applica- dial collateral ligament-tibia complex differed minimally
tion along the anatomic orientation of the ACL allows a between the lowest and highest rates of elongation. The
greater proportion of the fiber bundles to be loaded than ultimate load increased from 311.5 6 12.1 N at 0.008
does applying the force in an arbitrary direction. mm/s to 403.7 6 7.5 N at 113 mm/s. The mechanical
In a study performed on the human femur-ACL-tibia properties of the medial collateral ligament followed sim-
complex, using 27 pairs of cadaveric knees, the structural ilar trends, but the increases were even smaller. The ul-
properties of the ACL were examined by applying a force timate tensile strength of the medial collateral ligament
along the axis of the ACL as well as along the long axis of increased only 40% from the 0.01 to 200 percent per sec-
the tibia in the contralateral specimen.62 The structural ond strain. A similar study was also performed on the
properties for the femur-ACL-tibia complexes tested along rabbit ACL.18 Studies of the ACL at slow (0.003 mm/s),
the anatomic axis were significantly different from those medium (0.3 mm/s), and fast (113 mm/s) rates of elonga-
of the complexes tested along the tibial orientation. The tion showed similar effects. Small differences were ob-
linear stiffness for the femur-ACL-tibia complexes tested served in the modulus of elasticity between the slow and
in the anatomic orientation was 11% to 45% higher than medium strain rates, but the modulus at the fast exten-
for those tested in the tibial orientation, depending on sion rate was only 30% higher.
specimen age. The ultimate load of the femur-ACL-tibia Specimen Freezing for Storage. It is often necessary to
complexes was also 35% higher when tested in the ana- freeze tissue allografts before reconstruction, or to store a
tomic direction. Additionally, data from tests performed specimen before biomechanical testing. Therefore, the ef-
Vol. 27, No. 4, 1999 Biomechanics of Knee Ligaments 541

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forces in cruciate ligaments. Part II: The effect of section of the postero- ples to the study of the forces and motions of biological
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tendon. J Gen Physiol 43: 265–283, 1959 example six degrees of freedom describe the position of
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431, 1990 Hysteresis. Conversion of strain energy to heat during
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J Orthop Res 1: 22–29, 1983 †Adapted with permission from Simon.53
Vol. 27, No. 4, 1999 Biomechanics of Knee Ligaments 543

lost during each cycle of loading such that the unloading Strain. See “linear strain.”
path is offset from the loading path. Strain rate. Speed at which a material is deformed.
In situ. Latin: at a point; that is, in situ forces, which Stress. See “linear stress.”
are measured experimentally, represent the forces Stress relaxation. Decrease in stress at constant
present in a particular structure in its natural environ- strain by internal molecular rearrangement.
ment at a given position. Stress-strain plot. The experimental data relating
In vitro. Latin: in nonliving; that is, in vitro testing is stress (F/A) to strain (Dl/lo).
performed on a nonliving subject or nonliving specimen Tension. A force tending to elongate an object.
structures removed from their natural environments. Torque. See “moment.”
In vivo. Latin: in living; that is, in vivo testing is Translation. Linear motion of an object without regard
performed on a living subject. to rotation.
Kinematics. Description of motion made up of transla- Ultimate strain. Maximum strain sustained by the
tions and rotations about an axis, regardless of how the specimen before failure of the material.
motion came about. Ultimate stress. Maximum stress sustained by the
Linear strain (e). Change of length (Dl) divided by specimen before failure of the material.
original length (lo), such that e 5 Dl/lo. Uniaxial loading. A loading condition in which the
Material properties. Any physical characteristic of an force is applied along a single axis (that is, in one
object’s substance that is independent of the object’s struc- direction).
ture and geometry. Vector. A quantity that has a magnitude, a line of
Mechanical properties. A subset of material proper- application, and point of application, commonly repre-
ties that relates stresses to strains. sented by a directed line segment.
Normal stress. A force acting perpendicular to the area Viscoelastic. In biology, a property of a tissue that
of interest divided by that area. exhibits both viscous and elastic behavior (creep and
Range of motion. The range of translation and rota- stress relaxation). The material’s stress-strain behavior
tion of a joint for each of its six degrees of freedom. depends on strain rate.
Rotation. Revolving motion of an object about a point Young’s modulus (E). The intrinsic stiffness of a lin-
or an axis. ear material in tension or compression expressed as the
Stiffness. Resistance of a structure to a deformation. ratio of stress to strain: E 5 stress/strain.