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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.”
In the citing paper
“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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Comparison of ACL strain estimated via a data-driven model with in vitro measurements
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“Estimates of frontal (FACL−FP) and transverse (FACL−FP) plane ACL loading were based on cadaveric knee measurements (Markolf et al. 1990, 1995) and expressed as exponential functions of respective joint moment and θknee: (4)Ftf = F‖ + Fpat ⋅ cos pat + Fham ⋅ cos ham cos tf (5) Flig = F⟂ − Ftf ⋅ sin…”
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“These authors reported that isolated and increased quadriceps contraction significantly loads the ACL, but simultaneous hamstring contraction reduces this ACL strain [32,33,36,37].”
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“The load range in extension in this study corresponds well to the 50-240 N range demonstrated in the natural anterior cruciate ligament under experimental conditions by Markolf et al. 1990.”
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Assessments performed on harder surfaces can misrepresent ACL injury risk
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“Larger knee flexion moments have been associated with greater anterior translation of the tibia relative to the femur (Sell et al., 2007), which is a primary ACL loading mechanism (Markolf et al., 1990).”
Biomechanics of Lower Extremity Movements and Injury in Basketball
Taylor, J. B., Hegedus, E. J., & Ford, K. R. (2020) · Springer eBooks · doi:10.1007/978-3-662-61070-1_4 · Cited by 7
Reduction of Initial Tension in the In Situ Frozen Anterior Cruciate Ligament
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“In situ tension of the normal ACL, however, is reported to be nearly zero in the whole range of knee motion except for the full extension position.(16) Therefore, in ACL reconstruction, does a high tension applied to the autograft at the time of fixation remain high after the graft is remodeled in the joint cavity, or…”
BackgroundProdromos, C. C., Hecker, A. T., Joyce, B. T., et al. (2009) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-009-0761-9 · Cited by 7
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BackgroundDelta screw versus RetroScrew tibial fixation for ACL reconstruction
Rhee, P. C., Dahm, D. L., Stuart, M. J., et al. (2011) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1007/s00167-011-1543-8 · Cited by 7
“study simulates early rehabilitation with loads imposed on the ACL with passive knee extension [29], a frequency similar to a normal cadence [17], and the number of cycles similar to an early flexion/extension rehabilitation protocol [49].”
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Aflatounian, F., Becker, J., Hutchison, K. A., Simon, J. E., Grooms, D. R., & Monfort, S. M. (2025) · Orthopaedic Journal of Sports Medicine · doi:10.1177/23259671251378761 · Cited by 6
“32,35,36 Exploratory Outcomes—Contralateral ACL Injury Risk Factors After ACLR A post-hoc analysis, including biomechanical risk factors for contralateral injury after ACLR 28 that were reported during the progress of our study, was also incorporated for broader insight.”
Edman, G., Samuelsson, K., Senorski, E. H., Seil, R., & Cristiani, R. (2024) · The American Journal of Sports Medicine · doi:10.1177/03635465241288238 · Cited by 6
“Markolf et al 22,23 found higher ACL forces during knee hyperextension.”
Subject Specific Computational Models of the Knee to Predict Anterior Cruciate Ligament Injury
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Biphasic threat to femoral head perfusion in abduction: arterial hypoperfusion and venous congestion
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RetractedCristiani, R., Hansson, F., Senorski, E. H., et al. (2024) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1002/ksa.12568 · Cited by 5
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“The tension in the intact ACL has been reported to be less than 10 N from 10 to 120 of knee flexion, which increases to 50 to 100 N at full knee extension.(11) Mae et al(8) reported good clinical outcomes after anatomic ACL reconstruction using fixed-loop cortical suspension devices with a low initial tension of 20 N…”
BackgroundProximal Risk Factors for ACL Injury: Role of the Hip Joint and Musculature
Sigward, S. M., & Pollard, C. D. (2018) · Springer eBooks · doi:10.1007/978-3-662-56558-2_11 · Cited by 5
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“An in vitro study on fresh-frozen cadaver specimens reported the highest force experienced by the ACL was 118N, which occurred in 5 degrees of hyperextension, while minimal force was experienced by the ACL with the knee in greater than 10 degrees of flexion [29].”
BackgroundActivation and torque deficits in ACL‐reconstructed patients 4 months post‐operative
Nicol, C., Gouby, N., Coudreuse, J. M., et al. (2001) · European Journal of Sport Science · doi:10.1080/17461390100071203 · Cited by 5
“to this function, the ACL also restrains internal knee rotation (3).”
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Femoral Contact Forces in the Anterior Cruciate Ligament Deficient Knee: A Robotic Study
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Self-citationMartín, G. G., Martel, O., Yánez, A., et al. (2019) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-019-2435-1 · Cited by 5
“The 50–250 N load range simulated forces in the ACL during terminal passive extension of the knee [17].”
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The ACL: Anatomy, Biomechanics, Mechanisms of Injury, and the Gender Disparity
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“Hyperextension [ 15, 56 ] 4.”
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The Biomechanics of the Anterior Cruciate Ligament and Its Reconstruction
Jones, C. D. S., & Paul, N. (2011) · InTech eBooks · doi:10.5772/19939 · Cited by 5
“Studies where ACL-intact knees have been subjected to an internal rotation torque have shown increases in ACL strain, both in vitro (Ahmed et al., 1987; Bach & Hull, 1998) and in vivo (Fleming et al., 2001), and ACL force in vitro (Kanamori et al., 2000; Markolf et al., 1990).”
BackgroundArnold, M. P. (2004) · Radboud Repository (Radboud University) · Cited by 5
Characteristics of the female landing pattern
Saunders, N. (2006) · FedUni ResearchOnline (Federation University Australia) · Cited by 5
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Football Biomechanics and Performance Enhancement: A Systematic Review
Nazari, F., & Fatahi, A. (2023) · Journal of Sport Biomechanics · doi:10.61186/jsportbiomech.9.3.252 · Cited by 4
Boguszewski, D. V., Wagner, C. T., Butler, D. L., et al. (2015) · Journal of Orthopaedic Research® · doi:10.1002/jor.22958 · Cited by 4
The Anteromedial Tibial Rim Sign
Wissman, R. D., England, E. B., Mehta, K., et al. (2014) · Journal of Computer Assisted Tomography · doi:10.1097/rct.0000000000000160 · Cited by 4
“The ACL comes under strain with contraction of the quadriceps muscles as the joint nears full extension.(13,14) The quadriceps muscle pulls on the patellar tendon, causing anterior translation of the tibia.”
BackgroundEvidence-Based Management of Developmental Dysplasia of the Hip
Gardner, R. O. E., Alshryda, S. J., Kelley, S. P., et al. (2016) · Springer eBooks · doi:10.1007/978-3-319-41142-2_4 · Cited by 4
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Developing a Technique for the Imaging-Based Measurement of ACL Elongation: A Proof of Principle
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“The model is based on cadaveric data [18,19] and may be used to estimate ACL forces as a function of uniplanar (anterior drawer) force and knee joint angle.”
MethodRehabilitation Of Anterior Cruciate Ligament Injuries
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“The preconditioning stage was performed in order to stabilize the graft’s mechanical properties (8, 11, 12).”
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Proposal of Walking in Water for ACL Injury Rehabilitation Program by Simulation
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Functional anatomy and biomechanics of the anterior cruciate ligament
Fleming, B. C., Beynnon, B. D., & Pope, M. H. (1993) · Operative Techniques in Sports Medicine · doi:10.1016/s1060-1872(10)80022-x · Cited by 4
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Muscle-ligament interactions at the human knee (I)
Kim, S. (1998) · KSME International Journal · doi:10.1007/bf02942581 · Cited by 4
Neuromuscular Differences Between Men and Women
Sell, T. C., & Lephart, S. M. (2018) · Springer eBooks · doi:10.1007/978-3-662-56558-2_7 · Cited by 4
Anterior Cruciate Graft Tensioning
Vachtsevanos, J. G., Lamberson, K. A., & Paulos, L. E. (2003) · Techniques in Knee Surgery · doi:10.1097/00132588-200306000-00008 · Cited by 4
“This behavior is consistent with that reported in previous basic science studies.(19,26) Many in vitro studies have shown that increasing the amount of pretension alters the kinematics of the knee joint.”
BackgroundResultTokura, T., Matsushita, T., Nishida, K. K., et al. (2024) · Journal of Experimental Orthopaedics · doi:10.1002/jeo2.70021 · Cited by 3
“Previous literatures showed that there are higher forces generated in the ACL graft during knee hyperextension, and that might attribute to ACL graft stretching and failure [18, 17].”
BackgroundDifferences in Neuromuscular Characteristics between Male and Female Athletes
Sell, T. C., & Lephart, S. M. (2010) · Elsevier eBooks · doi:10.1016/b978-1-4160-5474-0.00017-5 · Cited by 3
Davies, W. T., & Read, P. J. (2022) · Strength and conditioning journal · doi:10.1519/ssc.0000000000000708 · Cited by 3
“Given the impact that joint kinematics can have on ACL strain (8,70,82,87,93,96,116), attempting to modify technical aspects which are associated with positions of high risk during cutting are warranted.”
BackgroundMethodInfluentialMoeinnia, H., Nourani, A., Mohseni, M., et al. (2023) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-023-06311-2 · Cited by 3
“This step was planned to simulate the ACL passive flexion-extension loading forces applied to the knee during the early rehabilitation process of a reconstructed graft [28, 29].”
BackgroundGraft fixation techniques in anterior cruciate ligament reconstruction – A narrative review
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Hansson, F., Stålman, A., Edman, G., Janarv, P., Moström, E. B., & Cristiani, R. (2025) · Knee Surgery Sports Traumatology Arthroscopy · doi:10.1002/ksa.12707 · Cited by 3
“The purpose of the ROM limits was to minimise ACL tension at 30° fl exion [29, 30].”
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“Some high resultant forces of the ACL are also measured under a tibial varus torque and would result in the ACL injury under this load condition, especially when the joint is at full extension [12, 13].”
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“Characteristics of the load–displacement curve (stiffness) of anterior knee laxity are thought to be important with respect to the clinical functioning of the knee joint [22] with alterations in loading range specific anterior knee stiffness postulated to be a factor in ACL injury risk [23].”
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“The multi-planar forces and moments are then transferred to the ACL to produce a [51, 56–58], musculoskeletal models [68, 71] and cadaveric experiments [53, 67, 72–76] resultant force on the tissue through complex non-linear dynamics (Fig.”
Biomechanics of Ligaments: From Molecular Biology to Joint Function
Woo, S. L., Hanford, S. D., & Moon, D. K. (2003) · Springer eBooks · doi:10.1007/978-1-4419-8967-3_2 · Cited by 2
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“Gracilis has been shown to contribute to hip joint flexion and adduction [15,55], with a negligible contribution to knee joint flexion [56].”
BackgroundFunction of the crocodilian anterior cruciate ligaments
Suzuki, D., Yamakawa, S., Iijima, M., et al. (2021) · Journal of Morphology · doi:10.1002/jmor.21401 · Cited by 2
“Its main function is to prevent anterior subluxation of the tibia with respect to the femur (Duthon et al., 2006; Fujie et al., 2011; Kanno et al., 2014; Markolf et al., 1990).”
BackgroundTesting of prototype interference screw for ACL reconstruction in porcine femurs
József, K., Nagy, P., Ákos, O., et al. (2011) · Biomechanica Hungarica · doi:10.15289/bh.v4i2.112 · Cited by 2
“Since data published in the literature consider ACL reconstruction fi xation with maximum load above 450–500 N as adequate 6,7,8 , it was concluded that our custom designed interference screw is appropriate for further researches.”
Arthroseentwicklung nach vorderer Kreuzbandruptur
Abermann, E., Hoser, C., Benedetto, K. P., et al. (2015) · Arthroskopie · doi:10.1007/s00142-014-0835-7 · Cited by 2
Relative Motion of ACL Insertion Points In Vivo: A Case Study, Including Skiing Maneuvers
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The Role of High Tibial Osteotomy in the ACL-Deficient Knee
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Wissman, R. D., England, E. B., Mehta, K., et al. (2014) · Journal of Computer Assisted Tomography · doi:10.1097/rct.0000000000000079 · Cited by 2
“Studies have shown that ACL comes under strain with contractions of the quadricep muscles as the joint nears full extension.(11,12) The quadricep muscle pulls on the patellar tendon, causing anterior translation of the tibia.”
BackgroundMechanical Properties and Biomechanical Function of the ACL
Fujie, H. (2016) · Springer eBooks · doi:10.1007/978-4-431-55858-3_6 · Cited by 3
SKIING EQUIPMENT: WHAT IS DONE TOWARDS MORE SAFETY, PERFORMANCE AND ERGONOMICS?
Senner, V. (2007) · doi:10.1201/9781439828427-140 · Cited by 2
Anatomy and Biomechanics of the Native Knee and Its Relevance for Total Knee Replacement
Muckenhirn, K. J., Chahla, J. A., & LaPrade, R. F. (2017) · Springer eBooks · doi:10.1007/978-3-662-54082-4_1 · Cited by 3
Ogasawara, I., Nambo, M., Uno, Y., et al. (2022) · Journal of Sports Sciences · doi:10.1080/02640414.2022.2133392 · Cited by 2
“In vitro studies have reported that the ACL strain (Bates et al., 2017; Oh et al., 2012) or resultant ACL force (Markolf et al., 1990) become smaller in response to the tibial external rotation moment than internal rotation moment.”
Background
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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