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Direct measurement of resultant forces in the anterior cruciate ligament. An in vitro study performed with a new experimental technique.
Abstract
A new technique was used to measure the resultant forces in the anterior cruciate ligament during a series of loading experiments on seventeen fresh-frozen cadaver specimens. The base of the ligament's tibial attachment was mechanically isolated with a coring cutter, and a specially designed load-transducer was fixed to the bone-plug that contained the ligament's tibial insertion so that the resultant forces were directly measured by the load-cell. Although the magnitudes of values for forces varied considerably between specimens for a given test condition, the patterns of loading with respect to direction of loading and the angle of flexion of the knee were remarkably consistent. Passive extension of the knee generated forces in the ligament only during the last 10 degrees of extension; at 5 degrees of hyperextension, the forces ranged from fifty to 240 newtons (mean, 118 newtons). When a 200-newton pull of the quadriceps tendon was applied to extend a knee slowly against tibial resistance, however, the force in the ligament increased at all angles of flexion of the knee. Internal tibial torque always generated greater forces in the ligament than did external tibial torque; higher forces were recorded as the knee was extended. The greatest forces (133 to 370 newtons) were generated when ten newton-meters of internal tibial torque was applied to a hyperextended knee. Fifteen newton-meters of applied varus moment generated forces of ninety-four to 177 newtons at full extension; fifteen newton-meters of applied valgus moment generated a mean force of fifty-six newtons, which remained unchanged with flexion of the knee. The force during straight anterior translation of the tibia was approximately equal to the anterior force applied to the tibia. The application of 925 newtons of tibiofemoral contact force reduced the mean force in the ligament that was generated by 200 newtons of anterior pull on the tibia by 36 per cent at full extension and 46 per cent at 20 degrees of flexion.
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“This approach is limited to ex vivo applications.”
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“investigators have proposed a technique involving the isolation of the tibial attachment of the cruciate ligament by creating a bone plug and attaching a load sensor to measure the native ACL force in cadaveric knees [5, 6].”
In the citing paper
“studies demonstrated that passive flexion–extension motions do not load the ACL [5, 30]”
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Contribution of biomechanics, orthopaedics and rehabilitation: The past, present and future
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Similar biomechanical properties of four tripled tendon graft models for ACL reconstruction
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Treatment of Anterior Cruciate Ligament Injuries
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Riley, J., Roth, J. D., Howell, S. M., et al. (2017) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-017-4776-3 · Cited by 23
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“In this condition, axial loading and forces due to muscle contraction could reduce rotation and translation compared to the passive condition.(22,34) The present study found a fatigue-induced increase in TT in females and a tendency towards a significant increase in males.”
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Hyper-elastic model analysis of anterior cruciate ligament
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Effect of knee musculature on anterior cruciate ligament strain in vivo
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Effect of suturing the femoral portion of a four‐strand graft during an ACL reconstruction
Camarda, L. K. C., Pitarresi, G., Moscadini, S., Marannano, G., Sanfilippo, A., & D’Arienzo, M. (2013) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-013-2449-4 · Cited by 21
“Specifically, loads between 50 and 250 N simulate previously measured forces in the ACL during passive extension of the knee [24], while a frequency of 1 Hz simulates the reported frequency of walking [19].”
BackgroundMethodRiley, J., Roth, J. D., Howell, S. M., et al. (2018) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-018-4841-6 · Cited by 22
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“The longest part of the ACL fibers, the proximal-posterior fibers, are almost loose during passive knee movement throughout entire range of motion except for 0 –10 (Markolf et al. 1990).”
BackgroundAnalysis of Different Stop-Jumping Strategies on the Biomechanical Changes in the Lower Limbs
Zhou, H., Xu, D., Chen, C., Ugbolue, U. C., Baker, J. S., & Gu, Y. (2021) · Applied Sciences · doi:10.3390/app11104633 · Cited by 21
Femoral Press-Fit Fixation of the Hamstring Tendons for Anterior Cruciate Ligament Reconstruction
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Reconstruction does not reduce tibial translation in the cruciate-deficient knee
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“5 Nm to define 0° flexion.(24) Kinematically aligned TKA was performed using cruciate‐retaining”
MethodLee, J., & Shin, C. S. (2020) · Gait & Posture · doi:10.1016/j.gaitpost.2020.08.130 · Cited by 20
Computational frame of ligament in situ strain in a full knee model
Adouni, M., Faisal, T. R., & Dhaher, Y. Y. (2020) · Computers in Biology and Medicine · doi:10.1016/j.compbiomed.2020.104012 · Cited by 20
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Effects of Proud Large Osteochondral Plugs on Contact Forces and Knee Kinematics: A Robotic Study
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Knee Joint Kinematics and Kinetics During a Lateral False-Step Maneuver
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The Effect of Muscles Fatigue on the Knee’s Kinetics and Kinematics Characteristics
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“During dynamic knee abduction, the medial collateral ligament, medial patellofemoral ligament, and ACL were mainly used to prevent excessive knee abduction [31].”
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Freutel, M., Seitz, A. M., Ignatius, A. A., et al. (2014) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-014-2951-3 · Cited by 18
“Similar approaches have been successfully realised in previous studies [12, 25].”
The anterior cruciate ligament—1
Karmani, S., & Ember, T. (2003) · Current Orthopaedics · doi:10.1016/s0268-0890(03)00102-6 · Cited by 18
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Effects of tibiofemoral compression on ACL forces and knee kinematics under combined knee loads
Markolf, K. L., Yamaguchi, K. T., Matthew, J., & McAllister, D. R. (2019) · Journal of Orthopaedic Research® · doi:10.1002/jor.24233 · Cited by 18
“Specific details of this ACL load measurement technique can be found in a prior publication.(43) All knee testing was performed using a 6-degree of freedom (DOF) robot (KR210; KUKA Robotics Corp.”
MethodSelf-citationUeno, R., Ishida, T., Yamanaka, M., et al. (2017) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-017-1832-6 · Cited by 18
Timing, not magnitude, of force may explain sex-dependent risk of ACL injury
Sigurðsson, H. B., Sveinsson, Þ., & Briem, K. (2018) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-018-4859-9 · Cited by 17
“The frequency with which VM, IRM, and vGRF coincide may be one factor that predisposes athletes to more frequent high loading on the ACL contributing to a fatigue-effect to a greater extent than these loads do in isolation.”
BackgroundInfluentialThe 1:1 versus the 2:2 Tunnel-Drilling Technique
Walsh, M. P., Wijdicks, C. A., Armitage, B. M., et al. (2009) · The American Journal of Sports Medicine · doi:10.1177/0363546509333013 · Cited by 18
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Koga, H., Muneta, T., Yagishita, K., Ju, Y., Mochizuki, T., Horie, M., Nakamura, T., Okawa, A., & Sekiya, I. (2013) · Arthroscopy The Journal of Arthroscopic and Related Surgery · doi:10.1016/j.arthro.2012.10.018 · Cited by 17
Effects of Pubertal Maturation on ACL Forces During a Landing Task in Females
Nasseri, A., Lloyd, D. G., MINAHAN, C. L., et al. (2021) · The American Journal of Sports Medicine · doi:10.1177/03635465211038332 · Cited by 17
Li, X., Adrien, N., Baker, J. S., Mei, Q., & Gu, Y. (2021) · Biology · doi:10.3390/biology10111184 · Cited by 18
“It may increase the pressure on the anterior cruciate ligament and increase the risk of knee injury [41,42].”
BackgroundBIOMECHANICAL STUDIES OF DOUBLE-BUNDLE POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONS
Markolf, K. L., Feeley, B. T., Jackson, S. R., et al. (2006) · Journal of Bone and Joint Surgery · doi:10.2106/00004623-200608000-00015 · Cited by 17
Self-citationRestrained tibial rotation may prevent ACL injury during landing at different flexion angles
Mokhtarzadeh, H., Ng, A., Yeow, C., et al. (2014) · The Knee · doi:10.1016/j.knee.2014.09.012 · Cited by 17
Meyer, E. G., Baumer, T. G., & Haut, R. C. (2010) · Journal of Biomechanical Engineering · doi:10.1115/1.4003135 · Cited by 17
Measurements of tibial rotation during a simulated pivot shift manoeuvre using a gyroscopic sensor
Petrigliano, F. A., Borgstrom, P. H., Kaiser, W. J., et al. (2014) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-014-3015-4 · Cited by 17
Self-citationHigh-load preconditioning of soft tissue grafts: an in vitro biomechanical bovine tendon model
Jaglowski, J. R., Williams, B. T., Turnbull, T. L., et al. (2014) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-014-3410-x · Cited by 17
Application of Isokinetics in Testing and Rehabilitation
Davies, G. J., & Ellenbecker, T. S. (2012) · Elsevier eBooks · doi:10.1016/b978-1-4377-2411-0.00025-3 · Cited by 17
Barnewolt, C. E., Jaramillo, D., Taylor, G. A., et al. (2003) · American Journal of Roentgenology · doi:10.2214/ajr.180.6.1801731 · Cited by 17
Lower extremity muscle contributions to ACL loading during a stop-jump task
Peel, S. A., Schroeder, L. E., & Weinhandl, J. T. (2021) · Journal of Biomechanics · doi:10.1016/j.jbiomech.2021.110426 · Cited by 16
Uno, Y., Ogasawara, I., Konda, S., Wakabayashi, K., Miyakawa, M., Nambo, M., Umegaki, K., Cheng, H., Hashizume, K., & Nakata, K. (2022) · Journal of Biomechanics · doi:10.1016/j.jbiomech.2022.111056 · Cited by 15
Mae, T., Shino, K., Matsumoto, N., Maeda, A., Nakata, K., & Yoneda, M. (2009) · Arthroscopy The Journal of Arthroscopic and Related Surgery · doi:10.1016/j.arthro.2009.07.016 · Cited by 16
Wu, J., Yeh, T., Shen, H., Cheng, C., & Lee, C.-H. (2009) · Clinical Biomechanics · doi:10.1016/j.clinbiomech.2009.02.003 · Cited by 16
“These loads approximate the forces that have been measured in the ACL during terminal passive extension of the knee (Markolf et al., 1990).”
BackgroundUeno, R., Navacchia, A., Schilaty, N. D., Myer, G. D., Hewett, T. E., & Bates, N. A. (2021) · Orthopaedic Journal of Sports Medicine · doi:10.1177/23259671211034487 · Cited by 15
“In vitro experimental testing indicates that quadriceps forces increase ACL loads, as opposed to hamstrings forces, which reduce ACL strain.(32,43,47) In quasi-static conditions, The Orthopaedic Journal of Sports Medicine, 9(9), 23259671211034487 DOI: 10.”
BackgroundConner, C. S., Morris, R. P., Vallurupalli, S., Buford, W. L., & Ivey, F. M. (2008) · Arthroscopy The Journal of Arthroscopic and Related Surgery · doi:10.1016/j.arthro.2008.07.006 · Cited by 15
Tibiofemoral Joint Kinetics during Squatting with Increasing External Load
Sahli, S., Rebai, H., Elleuch, M. H., Tabka, Z., & Poumarat, G. (2008) · Journal of Sport Rehabilitation · doi:10.1123/jsr.17.3.300 · Cited by 17
“They have used methods that included attaching buckle transducers to the ligaments(19,20) or attaching load cells to mechanically isolated bone plugs containing the tibial attachments of the ACL and the posterior cruciate ligament (PCL).(21,22) The two main disadvantages of in vitro methods are that it is very difficu…”
MethodJorn, L. P., Fridén, T., Ryd, L., et al. (1997) · Acta Orthopaedica Scandinavica · doi:10.3109/17453679708996256 · Cited by 15
“In our study we chose to tighten the sutures with only a 10-15 N load, in order to mimic the physiological low tension of the normal unloaded ACL in the semiflexed knee (Bylski-Austrow et al. 1990, Markolf et al. 1990), thereby avoiding to overconstrain the joint.”
MethodXiao, Y., Ling, M., Liang, Z., Ding, J., Zhan, S., Hu, H., & Chen, B. (2021) · International Journal of Computer Assisted Radiology and Surgery · doi:10.1007/s11548-021-02307-2 · Cited by 14
“In addition, studies demonstrated that passive flexion–extension motions do not load the ACL [5, 30], which is not completely consistent with the current results.”
BackgroundResultFoody, J. N., Bradley, P. X., Spritzer, C. E., Wittstein, J. R., DeFrate, L. E., & Englander, Z. A. (2023) · The American Journal of Sports Medicine · doi:10.1177/03635465221141876 · Cited by 14
“In support of this hypothesis, studies that analyzed bone bruise patterns in ACL-injured participants have suggested that the knee was positioned in extension near the time of noncontact ACL rupture.47,48,62 On the other hand, many studies have described a valgus collapse mechanism of noncontact ACL injury,42,56 which…”
BackgroundAnterior laxity of the knee assessed with gravity stress radiograph
Mae, T., Shino, K., Hiramatsu, K., et al. (2018) · Skeletal Radiology · doi:10.1007/s00256-018-2941-5 · Cited by 14
Qi, Y., Sun, H., Fan, Y., et al. (2018) · Journal of Back and Musculoskeletal Rehabilitation · doi:10.3233/bmr-169703 · Cited by 14
Can MRI predict the clinical instability and loss of the screw home phenomenon following ACL tear?
Ng, A. W. H., Griffith, J. F., Hung, E. H. Y., et al. (2012) · Clinical Imaging · doi:10.1016/j.clinimag.2012.03.001 · Cited by 14
“The anterior cruciate ligament (ACL) prevents both anterior tibial translation on the femur [1–9] and also prevents anterolateral rotatory instability [10–12].”
BackgroundShin, C. H., Hong, W. K., Lee, D. J., et al. (2017) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-017-1833-5 · Cited by 13
Randall, R. L., Wolf, E. M., Heilmann, M. R., et al. (1999) · Orthopedics · doi:10.3928/0147-7447-19990601-08 · Cited by 13
The anterior cruciate ligament—II
Karmani, S., & Ember, T. (2004) · Current Orthopaedics · doi:10.1016/s0268-0890(03)00103-8 · Cited by 13
Kia, M., Warth, L. C., Lipman, J. D., et al. (2017) · Journal of Orthopaedic Research® · doi:10.1002/jor.23838 · Cited by 13
“Altogether, a balanced fixed-bearing UKA did not capture the low ligament forces observed in the MCL and ACL during passive flexion.(12,38) In contrast to our findings, Patil et al.”
ResultBorjali, A., Nourani, A., Moeinnia, H., et al. (2021) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-021-04788-3 · Cited by 13
“techniques The ACS value, which is determined in the main cyclic loading, represents the resistance of the tendon itself against the forces applied on it during the knee’s flexion/extension in the early stage of the rehabilitation [34, 35, 37].”
MethodThe anterior cruciate ligament-deficient knee: compensatory mechanisms during downhill walking
Kuster, M. S., Sakurai, S., & Wood, G. (1995) · The Knee · doi:10.1016/0968-0160(95)00021-g · Cited by 13
Gamada, K. (2014) · International Journal of Physical Medicine & Rehabilitation · doi:10.4172/2329-9096.1000246 · Cited by 12
“larger strain than pure anterior force [125,199].”
Contact Forces Acting on Large Femoral Osteochondral Allografts During Forced Knee Extension
Du, P. Z., Markolf, K. L., Lama, C. J., McAllister, D. R., & Jones, K. J. (2017) · The American Journal of Sports Medicine · doi:10.1177/0363546517715726 · Cited by 12
Self-citationSharifi, M., Shirazi-Adl, A., & Marouane, H. (2018) · Journal of Biomechanics · doi:10.1016/j.jbiomech.2018.07.003 · Cited by 12
Casaletto, J. A., Perry, D. C., Foster, A., et al. (2009) · Journal of Bone and Joint Surgery · doi:10.2106/jbjs.h.00954 · Cited by 12
Christopher, R. C., Drouin, J. M., & Houglum, P. A. (2006) · Europe PMC (PubMed Central) · Cited by 13
The effect of anterior cruciate ligament graft rotation on knee laxity and graft tension
Hame, S. L., Markolf, K. L., Gabayan, A. J., et al. (2002) · Arthroscopy The Journal of Arthroscopic and Related Surgery · doi:10.1053/jars.2002.25971 · Cited by 12
Self-citationHaddara, R., Harandi, V. J., & Lee, P. V. S. (2021) · Orthopaedic Journal of Sports Medicine · doi:10.1177/2325967120981641 · Cited by 11
“This is a beneficial change, as the QUADS can strain the ACL when they contract at low flexion angles and have been shown to induce ACL tears in cadavers.(11,13,35,39,43) Cadaveric and in vivo studies(11,13,30,35,39) have shown that QUADS contraction has an effect on ACL strain between 0 to 45 of flexion.”
Background萩原, 敬., Terauchi, M., Hatayama, K., Yanagisawa, S., Ohsawa, T., & Kimura, M. (2021) · Arthroscopy The Journal of Arthroscopic and Related Surgery · doi:10.1016/j.arthro.2021.03.007 · Cited by 11
Ohori, T., Mae, T., Shino, K., Tachibana, Y., Fujie, H., Yoshikawa, H., & Nakata, K. (2017) · Journal of Experimental Orthopaedics · doi:10.1186/s40634-017-0087-3 · Cited by 11
“Thus, the ACL also had a restraining force against V-V rotation of the knee joint (Grood et al. 1981; Markolf et al. 1990).”
BackgroundSekiguchi, H., Post, W. R., Han, J., et al. (1998) · The Knee · doi:10.1016/s0968-0160(97)10011-4 · Cited by 11
Alteration in ACL loading after total and partial medial meniscectomy
Uzuner, S., & Li, L. (2024) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-024-07201-x · Cited by 11
“While some studies suggested that vertical compression can reduce ACL laxity [59–62] and promote ACL health [63], other studies indicated that it can increase ACL tensions [15, 61, 62, 64].”
Hurley, W. L., Boros, R. L., & Challis, J. H. (2003) · Clinical Biomechanics · doi:10.1016/j.clinbiomech.2003.09.004 · Cited by 10
“Simulations of the loads on the lower leg produced ACL strains similar to those measured previously in vitro (Markolf et al., 1990; Pioletti and Rakotomanana, 2000).”
MethodHigh-load preconditioning of human soft tissue hamstring grafts: An in vitro biomechanical analysis
Lockwood, W. C., Marchetti, D. C., Dahl, K. D., et al. (2016) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-016-4317-5 · Cited by 10
“5 Hz for 450 cycles to simulate an early postoperative rehabilitation protocol [21].”
MethodPetrović, M., Sigurðsson, H. B., Sigurðsson, H. J., et al. (2020) · Orthopaedic Journal of Sports Medicine · doi:10.1177/2325967120936980 · Cited by 10
In-vitro correlation between tension and length change in an anterior cruciate ligament substitute
Good, L. (1995) · Clinical Biomechanics · doi:10.1016/0268-0033(95)91398-x · Cited by 10
Parameter sensitivity of a mathematical model of the anterior cruciate ligament
Toutoungi, D. E., Zavatsky, A. B., & O'Connor, J. J. (1997) · Proceedings of the Institution of Mechanical Engineers Part H Journal of Engineering in Medicine · doi:10.1243/0954411971534340 · Cited by 10
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“Specifically, static preconditioning was performed to stabilize graft mechanical properties, while cyclic load simulate previously measured forces in the ACL during passive extension of the knee [12].”
Mae, T., Shino, K., Iuchi, R., Kinugasa, K., Uchida, R., Nakagawa, S., Yoshikawa, H., & Nakata, K. (2017) · Journal of Orthopaedic Science · doi:10.1016/j.jos.2017.05.006 · Cited by 11
Sigurðsson, H. B., & Briem, K. (2019) · Journal of Experimental Orthopaedics · doi:10.1186/s40634-019-0205-5 · Cited by 10
A Six-Degree-of-Freedom Test System for the Study of Joint Mechanics and Ligament Forces
Hollis, J. M. (1995) · Journal of Biomechanical Engineering · doi:10.1115/1.2794196 · Cited by 10
Martel, O., Carta, J. A., & Garcés, G. (2006) · Medical Engineering & Physics · doi:10.1016/j.medengphy.2006.01.013 · Cited by 10
Forman, D. A., Alizadeh, S., Button, D. C., et al. (2023) · International Journal of Sports Physical Therapy · doi:10.26603/001c.87764 · Cited by 9
A Comparison of Operative and Nonoperative Treatment of Anterior Cruciate Ligament Injuries
Secrist, E. S., Frederick, R. W., Tjoumakaris, F. P., et al. (2016) · JBJS Reviews · doi:10.2106/jbjs.rvw.15.00115 · Cited by 9
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Patellotibial contusions in anterior cruciate ligament tears
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Metadata
- Authors
- Markolf, K. L., Gorek, J. F., Kabo, J. M., & Shapiro, M. S.
- Affiliations
- University of California, Los Angeles (US)
- ORCID
- Markolf, K L
- Venue
- The Journal of Bone & Joint Surgery
- Published
- 1990-04
- Volume
- 72
- Issue
- 4
- Pages
- 557-567
- ISSN
- 0021-9355 (ISSN-L)
- OpenAlex
- W181468102
- Cited by
- 610
- References
- 0
- Citations by year
- 2026: 8 · 2025: 8 · 2024: 9 · 2023: 15 · 2022: 11 · 2021: 24 · 2020: 15 · 2019: 22 · 2018: 22 · 2017: 20 · 2016: 32 · 2015: 17 · 2014: 20 · 2013: 21 · 2012: 20
- FWCI
- 11.77
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Bone and Joint Surgery (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (5r01ar037037-03)
- National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01-AR37037)
- Topics
- Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
- Physical Sciences › Engineering › Biomedical Engineering › Lower Extremity Biomechanics and Pathologies
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Tendon Structure and Treatment
- Keywords
- anterior cruciate ligament, tibial attachment, knee hyperextension, tibiofemoral contact forces, anterior tibial translation, knee flexion angle
- MeSH terms
- Aged, Biomechanical Phenomena, Humans, Knee Joint, Ligaments, Articular, Middle Aged, Movement, In Vitro Techniques
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