䢇

Research Report
Neuromuscular Activation in
Conventional Therapeutic Exercises
and Heavy Resistance Exercises:
Implications for Rehabilitation
Background and Purpose. Central activation failure and muscular
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

atrophy are common after knee joint injury. Thus, exercises that aim to
stimulate muscular hypertrophy and increase neural drive to the
muscle fibers should be used during rehabilitation. This study exam-
ined the level of knee joint neuromuscular activation during 4 con-
ventional therapeutic exercises (quadriceps femoris muscle setting,
manual lateralization of the patella, rhythmic stabilization, and the
pelvic bridging exercise) and 4 heavy resistance exercises (free-weight
squat with a barbell, horizontal seated leg press, isolated knee exten-
sion with a cam mechanism, and isolated hamstring muscle curl) in
young, untrained men who were healthy. Subjects. Thirteen male
subjects (mean age⫽25.3 years, SD⫽3.0) with no previous history of
knee injury participated in the study. Methods. Neuromuscular activa-
tion during the exercises was defined as the root-mean-square (RMS)
electromyographic (EMG) signal normalized to the peak RMS EMG
signal of a maximal isometric muscle contraction. Results. Low levels of
neuromuscular activation were found during all conventional exercises
(⬍35%). A limitation may be that only a few of many different
conventional exercises were investigated. The highest level of neuro-
muscular activation (67%–79%) was observed during the open kinetic
chain resistance exercises (isolated knee extension and hamstring
muscle curl). None of the conventional exercises or heavy resistance
exercises were found to preferentially activate the vastus medialis
muscle over the vastus lateralis muscle. Discussion and Conclusion. The
results indicate that heavy resistance exercises should be included in
rehabilitation programs to induce sufficient levels of neuromuscular
activation to stimulate muscle growth and strength. [Andersen LL,
Magnusson SP, Nielsen M, et al. Neuromuscular activation in conven-
tional therapeutic exercises and heavy resistance exercises: implica-
tions for rehabilitation. Phys Ther. 2006;86:683– 697.]

Key Words: Electromyography, Neuromuscular activation, Neural drive, Physical therapy, Rehabilitation,
Resistance exercise, Strength, Training.

Lars L Andersen, S Peter Magnusson, Michael Nielsen, John Haleem, Kenn Poulsen, Per Aagaard
ўўўўўўўўўў

Physical Therapy . Volume 86 . Number 5 . May 2006 683

K
nee joint injuries frequently occur in a range
of sports.1 A major problem in relation to
injury is the subsequent muscle wasting and
loss of muscle strength (force-generating
capacity of muscle) in both young and elderly people.2– 6
Disuse atrophy of the quadriceps femoris muscle after
injury is frequently associated with chronic knee joint
instability,7 and persistent muscle atrophy has been
reported after serious knee joint injury (eg, anterior
cruciate ligament [ACL] rupture and subsequent recon-
struction).8,9 Central activation failure also has been
reported after knee joint injury.10 Furthermore, maxi-
mal muscle strength has been shown to be positively
correlated to function during daily living tasks (eg, stair
climbing) after ACL surgery.11 Thus, a major goal of
knee joint rehabilitation is to enhance neuromuscular
activation as well as stimulate muscle hypertrophy and
thereby increase muscle strength.
More than half a century ago, DeLorme and col-
leagues12,13 recommended the use of heavy resistance
training during rehabilitation following muscle and joint
injury. Heavy resistance exercise induces relatively high
levels of neuromuscular activation,14 which over a pro-
longed training period yields muscle hypertrophy,15–18
gains in muscle strength,19 –23 and enhanced neural drive
to the muscle fibers.17,24 –29 Despite these findings, tradi-
tional physical therapy commonly rehabilitates the mus-
cles and joints using “functional exercises,” static con-
tractions against no external resistance or dynamic
contractions with a fixed load (eg, the weight of the
body).30,31 Few studies have compared the effectiveness
of traditional physical rehabilitation paradigms versus
heavy resistance exercise. A recent study6 showed that
heavy resistance training, in contrast to traditional phys-
ical therapy, increased muscle mass, maximal muscle
strength, and neural drive in elderly individuals recover-
ing from long-term muscle disuse and hip surgery.
A key factor in muscle strength progression is the
“intensity” of exercise, which can be defined as a given
percentage of the maximal muscle contraction
strength.32 Electromyography (EMG) often is used as an
indicator of intensity of exercise. A positive linear rela-
tionship between isometric muscle force and surface
EMG amplitude has been documented previously.33–35
In addition, during dynamic muscle contraction, a pos-
itive proportionate relationship exists between muscle
force and EMG amplitude, although this relationship
may be slightly curvilinear in some muscles.36 –38 Despite
the inherent variance associated with measurements of
EMG activity, it is generally agreed that normalization of
the EMG amplitude with respect to the maximal EMG
amplitude obtained during isometric conditions
increases the reliability of the measurements.14,39 – 42
Thus, normalized EMG amplitude expressed as a per-
centage of the maximal EMG amplitude provides an
approximate estimate of exercise intensity. Normalized
EMG amplitude often is referred to as “the level of
neuromuscular activation.”19,25
Strength adaptations have been observed in training
studies where the intensity ranged between 40% and
95% of maximal intensity (for a review, see Fry43),
although it is generally agreed that intensities of at least
60% should be used for effective gains to occur.44 Thus,
for a given exercise, it would be reasonable to assume
that the level of neuromuscular activation should be at
least in the range of 40% to 60% to stimulate muscle
strength adaptations. Furthermore, it appears that a
dose-response relationship exists between intensity of exer-
cise and rate of muscle strength adaptations (ie, training at

LL Andersen, PhD Stud, MSc, is Exercise Physiologist and Researcher, National Institute of Occupational Health, Lersø Parkalle 105, DK 2100
Copenhagen Ø, Denmark, and Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, 2400 Copenhagen NV, Denmark
(ll_andersen@yahoo.dk). Address all correspondence to Dr Andersen.

SP Magnusson, PT, DSc, is Associate Professor, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital.

M Nielsen, PT, is Physical Therapist, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, and School of Physiotherapy, University
College South, Copenhagen, Denmark.

J Haleem, PT, is Physical Therapist, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, and School of Physiotherapy, University College
South.

K Poulsen, PT, is Physical Therapist, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, and School of Physiotherapy, University
College South.

P Aagaard, PhD, is Professor and Researcher, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense,
Denmark.

This study was approved by the local ethics committees of Copenhagen and Frederiksberg.

This article was received April 14, 2005, and was accepted November 29, 2005.

684 . Andersen et al Physical Therapy . Volume 86 . Number 5 . May 2006


Figure 1.
The 4 conventional exercises: quadriceps femoris muscle setting (upper left), manual lateralization of the patella (upper right), rhythmic stabilization
(lower left), and the pelvic bridging exercise (lower right).
higher levels of neuromuscular activation yields greater
strength gains).45– 47 It can be hypothesized that, due to
the relatively low external load, the level of neuromus-
cular activation during conventional therapeutic exer-
cises lies below the adaptive threshold of 40% to 60%
needed to stimulate gains in muscle strength and size.
The aim of the present study was to investigate the level
of knee joint neuromuscular activation with EMG during
conventional therapeutic exercises versus typical heavy
resistance exercises.
Method
Subjects
Thirteen young male subjects (mean age⫽25.3 years,
SD⫽3.0; mean height⫽181 cm, SD⫽4; mean
weight⫽75.8 kg, SD⫽6.2) with no previous history of
knee injury participated in the study. None of the
subjects had previously participated in regular resistance
training of the lower extremities. All subjects gave writ-
ten informed consent to participate in the study.
Conventional Exercises
Four exercises were examined: (1) quadriceps femoris
muscle setting (Fig. 1, upper left), (2) manual lateraliza-
Physical Therapy . Volume 86 . Number 5 . May 2006
ўўўўўўўўўўўўўўўўўўўўўў
tion of the patella (Fig. 1, upper right), (3) rhythmic
stabilization (Fig. 1, lower left), and (4) the pelvic
bridging exercise (Fig. 1, lower right). These exercises
are commonly used during rehabilitation for strength-
ening of the leg muscles and for proprioceptive training.
All subjects were familiarized with the exercises during a
visit to the laboratory before the start of the study. All
exercises were instructed by the same physical therapist.
Quadriceps femoris muscle setting. This exercise
involves isometric contraction at an extended knee joint
position against no external resistance. Subjects were
placed in a supine position with the knee and hip
extended. A small sandbag was positioned under the
knee. The subjects were instructed to contract the mus-
cles of the thigh as intensively as possible. This static
exercise is used to strengthen the quadriceps femoris
muscle during the early phase of rehabilitation where the
patient is incapable of performing dynamic exercises.48 –50
Manual lateralization of patella. With the subjects
relaxing in a supine position with the knee and hip
extended, the patella was displaced laterally by the
therapist using the largest possible pressure that did not
cause discomfort in the knee. The subjects were
Andersen et al . 685

Figure 2.
The 4 heavy resistance exercises: free-weight squat (upper left), horizontal seated leg press
(upper right), isolated knee extension (lower left), and isolated hamstring muscle curl (lower
right) (Technogym Isotonic Line).
instructed to contract the quadriceps femoris muscle,
and consequently patella moved medially (ie, back to the
neutral position). The exercise is thought to prefer-
entially activate and strengthen the vastus medialis
(VM) muscle, although this clinical belief lacks scien-
tific documentation.
Rhythmic stabilization. Subjects were in an upright
position with one leg flexed and the foot rested on a box.
The knee joint angle was approximately 60 to 70
degrees. The examiner placed his hands above and
below the subjects’ knee joint and encouraged the
subjects to hold the leg in the same position, while
manually applying moderate pressure in a rhythmic
fashion from various angles to the distal and proximal
parts of the thigh and lower leg, respectively. This
exercise is a proprioceptive neuromuscular facilitation
technique that is used to enhance proprioception and
stability of the knee joint through facilitated coactivation
of the muscles of the knee joint. Rhythmic stabilization is
a common rehabilitation technique that can be applied
to various joints and muscle groups.51
686 . Andersen et al
The pelvic bridging exercise. Subjects
were placed in a supine position on the
floor with the hip and knee joint flexed
(anatomical joint angles of ⬃45° and
100°–110°, respectively) and planta
pedis on the floor. The subjects were
instructed to lift the pelvis upward to
full hip extension, and subsequently
lower the body again. The exercise was
executed unilaterally to maximize the
load on the hamstring and gluteus mus-
cles. Range of motion of the knee joint
was approximately 20 degrees. The
exercise is believed to strengthen and
rehabilitate the hamstring and gluteus
muscles, and is commonly used for
patients with hip and knee injuries.52
Heavy Resistance Exercises
Four resistance exercises were exam-
ined: (1) free-weight squat with a bar-
bell (Fig. 2, upper left), (2) horizontal
seated leg press (Fig. 2, upper right),
(3) isolated knee extension with a cam
mechanism (Fig. 2, lower left), and (4)
isolated hamstring muscle curl (Fig. 2,
lower right).
Free-weight squats with a barbell. Sub-
jects were standing upright with a bar-
bell resting on the muscles of the neck
just below the vertebra prominens. The
subjects descended in a controlled manner by flexing
the knee and hip simultaneously to a knee joint angle of
approximately 100 degrees and a hip joint angle of
approximately 90 degrees and subsequently rose in a
similar fashion.
Horizontal seated leg press (Technogym Isotonic Line*).
Subjects were seated horizontally with straight legs and
45 degrees of hip flexion. The subjects bent the leg
(knee and hip joints) simultaneously to a knee joint
angle of approximately 100 degrees and subsequently
extended the leg in a similar fashion.
Isolated knee extension with a cam mechanism (Technogym
Isotonic Line). Subjects were seated upright with the
resistance pad resting on the tibia approximately 2 cm
above the medial malleolus. The starting position was a
knee joint angle of approximately 100 degrees. The
subjects extended the knee in a controlled manner and
subsequently flexed the knee back to the starting position.
* Technogym USA Corp, 830 Fourth Ave S, Suite 300, Seattle, WA 98134.
Physical Therapy . Volume 86 . Number 5 . May 2006
 ўўўўўўўўўўўўўўўўўўўўўў

Figure 3.
A typical recording of raw electromyographic activity during the rhythmic stabilization exercise. GM⫽gluteus maximus muscle, ST⫽semitendinosus
muscle, BF⫽biceps femoris caput longus muscle, RF⫽rectus femoris muscle, VM⫽vastus medialis muscle, VL⫽vastus lateralis muscle.

Isolated hamstring muscle curl (ie, knee flexion) with a cam
mechanism (Technogym Isotonic Line). Subjects were
lying in a prone position with straight legs and 10
degrees of hip flexion. The resistance pad was resting on
the lower leg about 10 cm above the insertion of the
Achilles tendon. The subjects flexed the knee to a knee
joint angle of approximately 100 degrees and subse-
quently lowered the weight again. The hip joint angle
was kept constant throughout the entire range of motion.
These exercises are commonly used in resistance train-
ing by both novice and experienced individuals.32 The
first 2 resistance exercises are aimed primarily at the
quadriceps femoris and gluteus muscles, the third exer-
cise is aimed primarily at the quadriceps femoris muscle,
and the fourth exercise is aimed primarily at the ham-
string muscles. The heaviest weight that could be lifted
10 times in a controlled manner without a break
(ie, 10-repetition maximum [RM]) was determined for
each exercise during 3 familiarization visits to the labo-

Physical Therapy . Volume 86 . Number 5 . May 2006 Andersen et al . 687

Figure 4.
A typical recording of knee joint position and raw electromyographic activity during 1 set of 5 repetitions of the squat exercise. The ascending and
descending parts of the position curve (bottom) represent the eccentric and concentric phases, respectively, of the exercise. GM⫽gluteus maximus muscle,
ST⫽semitendinosus muscle, BF⫽biceps femoris caput longus muscle, RF⫽rectus femoris muscle, VM⫽vastus medialis muscle, VL⫽vastus lateralis muscle.

688 . Andersen et al Physical Therapy . Volume 86 . Number 5 . May 2006

 ўўўўўўўўўўўўўўўўўўўўўў
ratory. In all repetition exercises, the
range of motion was from full knee
extension to a knee joint angle of
approximately 100 degrees.

Electromyography and Goniometry

The skin was shaved with a hand razor
and carefully cleaned with ethanol
before electrode placement. Bipolar
surface EMG electrodes (Medicotest
M-00-S†) with a 2.5-cm inter-electrode
distance were placed on the medial
portion of the vastus lateralis (VL), VM,
and rectus femoris (RF) muscles of the
quadriceps femoris muscle approxi-
mately 15, 13, and 20 cm above the
proximal border of the patella, respec-
tively; on the biceps femoris caput lon-
gus (BF) and semitendinosus (ST)
muscles of the hamstring muscle
approximately 20 cm from the fossa
poplitea; and finally on the middle of
the gluteus maximus (GM) muscle.
The EMG electrodes were connected
directly to small preamplifiers and led
through shielded wires to a differential
instrumentation amplifier with a band- Figure 5.
Quadriceps femoris muscle electromyographic (EMG) activity: vastus lateralis. Quadriceps
width of 10 to 1,000 Hz and a common femoris muscle EMG activity was highest during isolated knee extension. The EMG activity
mode rejection ratio better than 115 decreased gradually during more extended knee joint positions. Relatively low levels of
dB (Octopus AMT-8 EMG system‡). quadriceps femoris muscle neuromuscular activation were observed during the conventional
Aagaard et al53 previously documented exercises. Quadriceps femoris muscle setting produced the highest level of EMG activity among
that, with this experimental set-up, the the conventional exercises. RMS⫽root-mean-square, ISO⫽isometric “quadriceps femoris mus-
cle setting,” KNE⫽isolated knee extension, LEG⫽leg press, MAN⫽manual lateralization of the
amount of EMG crosstalk is negligible patella, RYT⫽rhythmic stabilization, SQU⫽squat.
(⬍2%– 6%).

Knee joint position was measured with

a flexible electrogoniometer,§ which was positioned lat-
erally over the right knee joint. Calibration of the
goniometer signal was performed at anatomical knee
joint angles of 0 and 90 degrees using a geometric
retractor.
The EMG and goniometer position signals were sampled
synchronously at 1,000 Hz and entered into a portable
computer using an external A/D converter (DT-9804㛳).
A sampling frequency of 1,000 Hz for surface EMG was
used in numerous previous studies,6,18,19,25,27,35,41,54 –56
because most of the surface EMG signal is concentrated
in the band between 20 and 200 Hz, and only negligible
content occurs beyond 500 Hz.57,58 Surface EMG mean
power frequency during maximal muscle contraction of
†
Medicotest A/S, Rugmarken 10, 3650 Ølstykke, Denmark.
‡
Bortec Biomedical Ltd, 239 Springborough Way, Calgary, Alberta, Canada T3H
5M8.
§
Penny & Giles, Christchurch, Dorset, United Kingdom.
㛳
Data Translation Inc, 100 Locke Dr, Marlborough, MA 01752-1192.
the respective muscles (VL, VM, RF, ST, and BF) has
been shown to be in the range of 70 to 115 Hz.19
Maximal Voluntary Isometric Contraction
Peak EMG amplitude was recorded during maximal
voluntary isometric contractions (MVICs) performed for
the knee extensor muscles (at 10° and 90°), knee flexor
muscles (at 10° and 90°), and hip extensor muscles (at 0°
and 90°). Two maximal trials of each exercise were
performed at the beginning of the test round, and 2
maximal trials of each exercise were performed at the
end of the test round. For each muscle, the peak EMG
amplitudes recorded at 10 and 90 degrees were not
significantly different. In addition, the pre- and post-
exercise peak EMG amplitudes were not significantly
different. Therefore, to reduce the inherent variance of
the recorded signal, the peak EMG amplitudes were
averaged across the 2 joint angles and the pre- and
post-exercise recordings for each muscle. This average

Physical Therapy . Volume 86 . Number 5 . May 2006 Andersen et al . 689

 load were performed. During the pelvic
bridging exercise, 5 repetitions with the
load of the body were performed. Dur-
ing the quadriceps femoris muscle set-
ting exercise, 5 isometric contractions
of 3 to 4 seconds were performed.
During manual lateralization of the
patella, 5 repetitions were performed.
During rhythmic stabilization, pressure
was applied for 15 seconds above and
below the knee from different angles.
At the end of the third round of tests,
2 MVICs of the knee extensor, knee
flexor, and hip extensor muscles were
performed again.

Off-line Signal Processing

During the subsequent process of off-
line analysis, the goniometer position
signal was digitally low-pass filtered at a
cutoff frequency of 10 Hz using a
fourth-order zero-phase-lag Butter-
worth filter.58 All raw EMG signals were
digitally high-pass filtered at a cutoff
frequency of 5 Hz using a fourth-order
zero-phase-lag Butterworth filter.58 Sub-
sequently, the EMG signal was pro-
cessed by a symmetric moving root-
Figure 6. mean-square (RMS) filter with a time
Quadriceps femoris muscle electromyographic (EMG) activity: vastus medialis. Quadriceps constant of 50 milliseconds. The RMS
femoris muscle EMG activity was highest during isolated knee extension. The EMG activity EMG signal was averaged in 10-degree
decreased gradually during more extended knee joint positions. Relatively low levels of knee joint angle intervals (ie. 10°–20°,
quadriceps femoris muscle neuromuscular activation were observed during the conventional
exercises. Quadriceps femoris muscle setting produced the highest level of EMG activity among
20°–30°, . . . 90°–100°) for the concen-
the conventional exercises. RMS⫽root-mean-square, ISO⫽isometric “quadriceps femoris mus- tric phase of the dynamic exercises
cle setting,” KNE⫽isolated knee extension, LEG⫽leg press, MAN⫽manual lateralization of the (squat, leg press, knee extension, ham-
patella, RYT⫽rhythmic stabilization, SQU⫽squat. string muscle curl, and the pelvic bridg-
ing exercise), and averaged over a
1-second period around the peak RMS
peak EMG value was used for the EMG normalization EMG amplitudes for the isometric exercises (quadriceps
procedure (see “Off-line Signal Processing” section). femoris muscle setting, manual lateralization of patella,
and rhythmic stabilization). To reduce the variability of
Exercise Protocol the signal obtained, the RMS EMG amplitudes were
On the day of testing, the subjects warmed up on a averaged over the 5 repetitions and 3 sets for each
Monark bicycle ergometer# at 100 W for 10 minutes. exercise (ie, total of 15 contractions). Finally, average
Two MVICs of the knee extensor, knee flexor, and hip RMS EMG amplitudes during the exercises were normal-
extensor muscles were performed to obtain maximal ized relative to the isometric peak RMS EMG signal.59
EMG signal amplitude. Then 3 rounds of the following The term “neuromuscular activation” refers to the nor-
exercises were performed in a cyclic manner: squat, malized RMS EMG amplitudes.
isolated knee extension, leg press, hamstring muscle
curl, the pelvic bridging exercise, quadriceps femoris Data Analysis
muscle setting, manual lateralization of the patella, and An analysis of variance with a subsequent Bonferroni
rhythmic stabilization. Four minutes of rest was allowed corrected post hoc test was used to answer the question of
between exercises to avoid fatigue. During the resistance whether normalized RMS EMG amplitudes differed
exercises, 5 repetitions with a predetermined 10-RM between the exercises. Values are reported as mean ⫾
standard error unless otherwise stated. P ⬍.05 was
accepted as significant.
#
Monark Exercise AB, Kroonsväg 1, S-7080 50 Vansbro, Sweden.

690 . Andersen et al Physical Therapy . Volume 86 . Number 5 . May 2006

 ўўўўўўўўўўўўўўўўўўўўўў
quadriceps femoris muscle EMG ampli-
tudes ranked as follows: isolated knee
extension ⬎ leg press ⬎ squat ⬎ quad-
riceps femoris muscle setting ⬎ manual
lateralization of the patella ⬎ rhythmic
stabilization (Tab. 1). Quadriceps fem-
oris muscle EMG amplitudes decreased
markedly during gradual extension of
the knee in the squat and leg press
exercises (Figs. 5–7). None of the exer-
cises selectively activated the VM mus-
cle more than the VL muscle (Tab. 1),
which also was evidenced by the fact
that the VM/VL EMG ratio did not
significantly exceed 1.00 at any knee
joint angle or in any exercise (Fig. 8).

Hamstring muscle EMG was highest

during isolated hamstring muscle curl
(Figs. 9 and 10), with normalized RMS
EMG amplitudes of 67% to 70%
(Tab. 2). Antagonist coactivation of the
hamstring muscles during squat and
leg press exercises yielded similar EMG
values (19%– 40%) compared with the
pelvic bridging exercise (24%–34%)
where the hamstring muscles acted as
Figure 7. agonists (Tab. 2). Between exercises,
Quadriceps femoris muscle electromyographic (EMG) activity: rectus femoris. Quadriceps hamstring muscle (BF) EMG ampli-
femoris muscle EMG activity was highest during isolated knee extension. The EMG activity
decreased gradually during more extended knee joint positions. Relatively low levels of
tudes ranked as follows: isolated ham-
quadriceps femoris muscle neuromuscular activation were observed during the conventional string muscle curl ⬎ the pelvic bridging
exercises. Quadriceps femoris muscle setting produced the highest level of EMG activity among exercise, leg press, squat ⬎ isolated
the conventional exercises. RMS⫽root-mean-square, ISO⫽isometric “quadriceps femoris mus- knee extension ⬎ quadriceps femoris
cle setting,” KNE⫽isolated knee extension, LEG⫽leg press, MAN⫽manual lateralization of the muscle setting ⬎ rhythmic stabilization
patella, RYT⫽rhythmic stabilization, SQU⫽squat.
(Tab. 2). Gluteus maximus muscle
EMG activity was higher in squat and
leg press exercises (55%– 60%) com-
Results pared with the pelvic bridging exercise (36%) (Tab. 3).
Typical recordings of raw EMG activity and goniometer Training loads lifted in the squat, leg press, isolated knee
position signals are given in Figs. 3 and 4. Normalized extension, and hamstring muscle curl exercises were
RMS EMG values throughout the entire range of motion 73⫾13 (X⫾SD) kg (range⫽60 –95 kg), 240⫾39 kg
are presented in Figs. 5 to 10, and average values for (range⫽145–280 kg), 68⫾18 kg (range⫽35–100 kg),
range of motion of 10 to 100 degrees are presented in and 48⫾9 kg (range⫽35– 60 kg), respectively.
Tables 1 through 3. Generally, EMG activity was mark-
edly higher during the resistance exercises compared Discussion and Conclusions
with the conventional exercises (Tabs. 1–3). Normalized This study examined the level of neuromuscular activa-
RMS EMG amplitudes were between 9% and 34% dur- tion during typical therapeutic exercises and heavy resis-
ing the conventional exercises and between 12% and tance exercises. A central dogma in conventional physi-
86% during the resistance exercises when the total range cal therapy is to strengthen the target muscles using
of motion was considered (Figs. 5–10). functional exercises. The therapeutic exercises that we
examined in this study (Fig. 1) are widely used within
The VL, VM, and RF of the quadriceps femoris muscle physical therapy to strengthen the muscles of the knee
demonstrated similar EMG patterns. Quadriceps femoris joint and are considered essential during rehabilitation
muscle EMG activity was greatest during isolated knee following injury.30,31 In light of this, the central finding
extension (Figs. 5–7), with normalized RMS EMG ampli- of our study was that relatively low levels of neuromus-
tudes of 68% to 74% (Tab. 1). Between exercises, cular activation were observed in all of the conventional

Physical Therapy . Volume 86 . Number 5 . May 2006 Andersen et al . 691


Figure 8.
No preferential activation of vastus medialis muscle (VM) over vastus lateralis muscle (VL) was lated knee extension at more extended
seen in any exercise or during any knee joint range of motion because the VM/VL positions. The discrepancy between the
electromyographic activity ratio did not significantly exceed 1.00. ISO⫽isometric “quadriceps present and previous results may be
femoris muscle setting,” KNE⫽isolated knee extension, LEG⫽leg press, MAN⫽manual lateral-
ization of the patella, SQU⫽squat.
exercises (Figs. 5–10). Below, the aspect of neuromuscu-
lar activation is discussed in relation to the potential
benefits and limitations of these exercises.
Quadriceps Femoris Muscle Neuromuscular Activation
Central activation failure and persistent quadriceps fem-
oris muscle atrophy have been reported after certain
types of knee joint injury.8 –10 Thus, a major goal of
rehabilitation should be to stimulate neuromuscular
activation and enhance muscle growth. The quadriceps
femoris muscle setting exercise (Fig. 1) is a widely used
isometric exercise during the early phase of rehabilita-
tion when the patient is incapable of performing
dynamic exercises.48 –50 Although this specific exercise
induced the greatest magnitude of quadriceps femoris
muscle neuromuscular activation of the 4 conventional
exercises examined (32%, 30%, and 24% for the VL,
VM, and RF, respectively), the neuromuscular activation
was below the threshold of 40% to 60% to induce
significant hypertrophy and strength gains over a pro-
longed period of training. Furthermore, isometric exer-
692 . Andersen et al
cises may not optimally stimulate
strength adaptations.60,61 Nevertheless,
the quadriceps femoris muscle setting
exercise may be helpful to lessen mus-
cle wasting during phases of joint
immobilization where dynamic exer-
cises are rendered impossible. The low
magnitude of neuromuscular activation
during manual lateralization of patella
and rhythmic stabilization exercises
(8%–17%, Tab. 1) indicates that these
exercises are not efficient in strength-
ening the quadriceps femoris muscle. It
can be speculated, however, that such
exercises may have merit in proprio-
ceptive training.51
Among the resistance exercises, overall
quadriceps femoris muscle EMG activ-
ity was highest during isolated knee
extension (Figs. 5–7). In contrast, Esca-
milla et al14 reported that, in experi-
enced weight lifters, quadriceps femo-
ris muscle EMG activity was higher in
squat and leg press exercises compared
with isolated knee extension at more
flexed knee joint positions, although
EMG activity was highest during iso-
related to the training status of the
subjects (ie, novice versus experienced
subjects). The role of task learning and
improved intermuscular coordination
plays a major role in strength development during the
initial weeks of training, especially when complex exer-
cises are used.62 The isolated knee extension exercise is
a simple single-joint movement, whereas the squat and
leg press exercises are more functional and complex
multijoint movements, which may explain the higher
neuromuscular activation in isolated knee extension in
novice subjects (Figs. 5–7). Thus, a combination of
simple and complex exercises probably should be used
during rehabilitation to optimally stimulate maximal
muscle strength and hypertrophy and to improve pos-
tural balance and intermuscular coordination.
Safety Aspects
The safety aspects of heavy resistance exercise in relation
to rehabilitation also should be considered. A concern
regarding isolated knee extension has been that this type
of exercise imposes greater stress on the ACL compared
with the squat and leg press exercises, especially in more
extended knee joint positions.14,63– 65 However, neither
isolated knee extension nor any other type of controlled
Physical Therapy . Volume 86 . Number 5 . May 2006

Figure 9.
Hamstring muscle electromyographic (EMG) activity: biceps femoris caput longus. Hamstring other types of knee joint exercises do
muscle EMG activity was highest during isolated hamstring muscle curl exercise. Relatively low
levels of hamstring muscle neuromuscular activation were observed during the conventional
exercises. RMS⫽root-mean-square, ISO⫽isometric “quadriceps femoris muscle setting,” activation of the VM over VL,
HAM⫽hamstring muscles, PEL⫽pelvic bridging exercise, RYT⫽rhythmic stabilization.
heavy resistance exercise produces higher compressive
or tensile forces on the structures of the knee joint
compared with many activities of daily living.14 More-
over, the results of a recent resistance training study66
suggest that, after ACL surgery, maximal muscle contrac-
tions are not associated with anterior knee pain. To our
knowledge, no previous researchers have reported seri-
ous knee joint injuries specifically due to heavy resis-
tance exercise. Furthermore, resistance training is asso-
ciated with a very low incidence of injury compared with
other types of training.67 Thus, considering the high
level of neuromuscular activation as well as its simplicity,
the isolated knee extension exercise appears to be highly
efficient during rehabilitation. The relatively high level
of quadriceps femoris muscle neuromuscular activation
during the flexed knee joint position of the leg press and
squat exercises (Figs. 5–7), combined with a high degree
of functionality, indicates that these exercises also could
be included in the rehabilitation from knee joint injury.
Physical Therapy . Volume 86 . Number 5 . May 2006
ўўўўўўўўўўўўўўўўўўўўўў
Preferential VM Neuromuscular
Activation
It is a common clinical observation that
the VM appears to be more profoundly
atrophied than the other components
of the quadriceps femoris muscle after
injury.68 –70 Although in many instances
this observation may be a visual arti-
fact,10 there may be cases where the VM
needs specific strengthening.71 The VM
acts as an antagonist to the VL in
aligning the patella relative to the line
of pull of the quadriceps femoris
muscle.48,69,72,73 Thus, weakening of the
VM may increase the tendency of the
patella to migrate laterally. A number
of exercises have been suggested to
strengthen the VM preferentially.74,75
Manual lateralization of the patella
(Fig. 1) has been widely used during
rehabilitation to preferentially activate
and strengthen the VM muscle. In the
present study, the use of this exercise to
preferentially activate the VM over the
VL was not substantiated because the
VL and VM showed similar levels of
neuromuscular activation (17% and
16% respectively, Tab. 1). Likewise,
not seem to produce a preferential
76 – 80
which is supported by the present
results (Tab. 1). Some studies81,82 have
indicated greater VM activation in the
terminal phase of knee extension, whereas Gryzlo et al83
reported no preferential activation in this phase of
motion. In the present study, no indications of prefer-
ential VM recruitment were observed near full extension
of the knee joint, as evidenced by the fact that the
VM/VL ratio of EMG values did not exceed 1.00 in any
knee joint position or in any exercise (Fig. 8). It should
be noted, however, that preferential activation of the VM
over the VL can be obtained with myoelectrical stimula-
tion therapy.84,85
Hamstring Muscle Neuromuscular Activation
A high level of hamstring muscle strength has been
suggested to provide potential protection of the knee
joint in athletes who are healthy as well as in patients
with ACL injuries.86 Hamstring muscle coactivation dur-
ing forceful knee extension reduces the anterior shear of
the tibia relative to the femur, thereby reducing the
tensile stress on the ACL.87,88 The purpose of the pelvic
bridging exercise is to strengthen and rehabilitate the
hamstring and gluteus muscles, and this exercise is often
used during rehabilitation for patients with knee or hip
Andersen et al . 693
 injuries.52 The relatively low level of
neuromuscular activation for the BF
(34%), ST (24%), and GM (36%) in
the pelvic bridging exercise suggests
that this exercise does not effectively
stimulate muscle strength gains. In
comparison, antagonist coactivation of
the hamstring muscles during the squat
and leg press exercises produced simi-
lar EMG amplitudes compared with
that of the pelvic bridging exercise
where the hamstring muscles acted as
agonists (Tab. 2). Hamstring muscle
neuromuscular activation was found to
be highest during the isolated ham-
string muscle curl exercise. Thus, the
isolated hamstring muscle curl exercise
appears to be the most efficient exer-
cise to strengthen the hamstring mus-
cles in novice subjects. Furthermore,
during the hamstring muscle curl exer-
cise, a very homogenous level of BF and
ST neuromuscular activation was
observed (70% and 67%, respectively),
in contrast to a more differential BF
and ST activation pattern during the
other exercises (Tab. 2). In agreement
Figure 10. with previous findings,14 a preferential
Hamstring muscle electromyographic (EMG) activity: semitendinosus. Hamstring muscle EMG recruitment of the BF over the ST was
activity was highest during isolated hamstring muscle curl exercise. Relatively low levels of
hamstring muscle neuromuscular activation were observed during the conventional exercises.
observed during the leg press, squat,
RMS⫽root-mean-square, ISO⫽isometric “quadriceps femoris muscle setting,” HAM⫽hamstring and isolated knee extension exercises
muscles, PEL⫽pelvic bridging exercise, RYT⫽rhythmic stabilization. (Tab. 2) where the hamstring muscles
act as an antagonist to the quadriceps
femoris muscle. A preferential BF
Table 1. recruitment also has been observed during isolated knee
Normalized Root-Mean-Square Electromyography Values in extension performed in an isokinetic dynamometer and
Descending Order for the Vastus Lateralis (VL), Vastus Medialis (VM),
and Rectus Femoris (RF) Muscles (Average Values⫾Standard Error has been speculated to be a protective effect to avoid
Throughout the 10°–100° Range of Motion) a excessive medial rotation of the tibia, which imposes
stress on the ACL during forceful quadriceps femoris
VL VM RF muscle contraction.53

KNE 74%⫾15% 79%⫾25% 68%⫾9% A limitation of this study may be that uninjured subjects
...........................................................................
LEG 53%⫾13% 54%⫾8% 39%⫾13% were used. Thus, a deficit in neuromuscular activation
...........................................................................
SQU 43%⫾11% 45%⫾10% 27%⫾9%
...........................................................................
may be expected in injured individuals compared with
ISO 32%⫾11% 30%⫾11% 24%⫾7% uninjured individuals.3,10 However, this deficit would
...........................................................................
MAN 17%⫾7% 16%⫾6% 12%⫾4%
likely vary among various injury conditions, making it
........................................................................... difficult to achieve any meaningful comparison among
RYT 10%⫾5% 9%⫾4% 8%⫾3%
HAM 9%⫾6% 9%⫾6% 8%⫾5%
different types of knee joint injuries. Future studies
PEL 6%⫾4% 6%⫾4% 5%⫾4% should be conducted to investigate the effectiveness of
a
these exercises in relation to various injury conditions. A
Dotted separation lines indicate significant difference between exercises
(P ⬍.05). HAM⫽isolated hamstring muscle curl, ISO⫽isometric “quadriceps
strength of this study was that non–resistance-trained
femoris muscle setting,” KNE⫽isolated knee extension, LEG⫽leg press, subjects were used. Thus, the results may well relate to
MAN⫽manual lateralization of the patella, PEL⫽pelvic bridging exercise, injured individuals because most people who undergo
RYT⫽rhythmic stabilization, SQU⫽squat.
rehabilitation are novices with regard to resistance train-
ing. Thus, we conclude that the conventional exercises
used in this study produce levels of neuromuscular

694 . Andersen et al Physical Therapy . Volume 86 . Number 5 . May 2006

 ўўўўўўўўўўўўўўўўўўўўўў
Table 2. References
Normalized Root-Mean-Square Electromyography Values in 1 Dugan SA. Sports-related knee injuries in female athletes: what gives?
Descending Order for the Biceps Femoris Caput Longus (BF) and Am J Phys Med Rehabil. 2005;84:122–130.
Semitendinosus (SF) Muscles (Average Values⫾Standard Error
Throughout the 10°–100° Range of Motion)a 2 De Baere T, Geulette B, Manche E, Barras L. Functional results after
surgical repair of quadriceps tendon rupture. Acta Orthop Belg. 2002;
68:146 –149.
BF ST
3 Kannus P, Jarvinen M. Thigh muscle function after partial tear of the
HAM 70%⫾14% 67%⫾13% medial ligament compartment of the knee. Med Sci Sports Exerc.
...........................................................
1991;23:4 –9.
LEG 40%⫾17% 22%⫾9%
PEL 34%⫾14% 24%⫾6% 4 Lorentzon R, Elmqvist LG, Sjostrom M, et al. Thigh musculature in
................
SQU 35%⫾14% 19%⫾6% relation to chronic anterior cruciate ligament tear: muscle size, mor-
........................................................... phology, and mechanical output before reconstruction. Am J Sports
KNE 23%⫾13% 9%⫾4% Med. 1989;17:423– 429.
...............
ISO 17%⫾13% 12%⫾11% 5 Nakamura T, Kurosawa H, Kawahara H, et al. Muscle fiber atrophy in
RYT 11%⫾5% 11%⫾6% the quadriceps in knee-joint disorders: histochemical studies on 112
MAN 12%⫾7% 9%⫾6% cases. Arch Orthop Trauma Surg. 1986;105:163–169.
a
Dotted separation lines indicate significant difference between exercises 6 Suetta C, Aagaard P, Rosted A, et al. Training-induced changes in
(P ⬍.05). HAM⫽isolated hamstring muscle curl, ISO⫽isometric “quadriceps muscle CSA, muscle strength, EMG, and rate of force development in
femoris muscle setting,” KNE⫽isolated knee extension, LEG⫽leg press,
elderly subjects after long-term unilateral disuse. J Appl Physiol. 2004;
MAN⫽manual lateralization of the patella, PEL⫽pelvic bridging exercise,
RYT⫽rhythmic stabilization, SQU⫽squat.
97:1954 –1961.
7 Baugher WH, Warren RF, Marshall JL, Joseph A. Quadriceps atrophy
in the anterior cruciate insufficient knee. Am J Sports Med. 1984;12:
Table 3.
Normalized Root-Mean-Square Electromyography Values in 192–195.
Descending Order for the Gluteus Maximus Muscle (Average 8 Arangio GA, Chen C, Kalady M, Reed JF III. Thigh muscle size and
Values⫾Standard Error Throughout the 10°–100° Range of Motion)a strength after anterior cruciate ligament reconstruction and rehabili-
tation. J Orthop Sports Phys Ther. 1997;26:238 –243.
LEG 60%⫾16% 9 Pfeifer K, Banzer W. Motor performance in different dynamic tests in
SQU 55%⫾14% knee rehabilitation. Scand J Med Sci Sports. 1999;9:19 –27.
................
PEL 36%⫾12% 10 Williams GN, Buchanan TS, Barrance PJ, et al. Quadriceps weak-
HAM 28%⫾14% ness, atrophy, and activation failure in predicted noncopers after
ISO 27%⫾14%
................ anterior cruciate ligament injury. Am J Sports Med. 2005;33:402– 407.
MAN 20%⫾16%
11 Morrissey MC, Hooper DM, Drechsler WI, Hill HJ. Relationship of
KNE 18%⫾10%
................ leg muscle strength and knee function in the early period after
RYT 11%⫾9% anterior cruciate ligament reconstruction. Scand J Med Sci Sports.
a
2004;14:360 –366.
Dotted separation lines indicate significant difference between exercises
(P ⬍.05). HAM⫽isolated hamstring muscle curl, ISO⫽isometric “quadriceps 12 DeLorme TL. Restoration of muscle power by heavy resistance
femoris muscle setting,” KNE⫽isolated knee extension, LEG⫽leg press, exercises. J Bone Joint Surg Am. 1945;27:645– 667.
MAN⫽manual lateralization of the patella, PEL⫽pelvic bridging exercise,
RYT⫽rhythmic stabilization, SQU⫽squat. 13 DeLorme TL, West FE, Shriber WJ. Influence of progressive resis-
tance exercises on knee function following femoral fractures. J Bone
Joint Surg Am. 1950;32:910 –924.
activation that are below the threshold of 40% to 60% to 14 Escamilla RF, Fleisig GS, Zheng N, et al. Biomechanics of the knee
effectively stimulate muscle strength gains. It should be during closed kinetic chain and open kinetic chain exercises. Med Sci
Sports Exerc. 1998;30:556 –569.
recognized, however, that only a few of many different
conventional exercises were investigated and that more 15 Aagaard P, Andersen JL, Dyhre-Poulsen P, et al. A mechanism for
challenging and intense exercises may yield higher levels increased contractile strength of human pennate muscle in response
to strength training: changes in muscle architecture. J Physiol. 2001;
of neuromuscular activation. The open kinetic chain 534:613– 623.
resistance exercises (isolated knee extension and ham-
16 Andersen LL, Tufekovic G, Zebis MK, et al. The effect of resistance
string muscle curl) produced the highest levels of neu-
training combined with timed ingestion of protein on muscle fiber size
romuscular activation in novice subjects. The closed and muscle strength. Metabolism. 2005;54:151–156.
kinetic chain resistance exercises (squat and leg press)
17 Narici MV, Roi GS, Landoni L, et al. Changes in force, cross-
also produced relatively high levels of neuromuscular sectional area and neural activation during strength training and
activation in the flexed knee joint position. Based on the detraining of the human quadriceps. Eur J Appl Physiol Occup Physiol.
present results, therefore, we recommend the use of 1989;59:310 –319.
controlled heavy resistance exercise as a supplement to 18 Narici MV, Hoppeler H, Kayser B, et al. Human quadriceps cross-
the traditional physical therapy regimens used in knee sectional area, torque and neural activation during 6 months strength
injury rehabilitation to induce sufficient levels of neuro- training. Acta Physiol Scand. 1996;157:175–186.
muscular activation and thereby stimulate muscle
growth and strength.

Physical Therapy . Volume 86 . Number 5 . May 2006 Andersen et al . 695

19 Aagaard P, Simonsen EB, Andersen JL, et al. Neural inhibition
during maximal eccentric and concentric quadriceps contraction:
effects of resistance training. J Appl Physiol. 2000;89:2249 –2257.
20 Andersen LL, Andersen JL, Magnusson SP, et al. Changes in the
human muscle force-velocity relationship in response to resistance
training and subsequent detraining. J Appl Physiol. 2005;93:511–518.
21 Colliander EB, Tesch PA. Effects of eccentric and concentric
muscle actions in resistance training. Acta Physiol Scand. 1990;140:
31–39.
22 Hakkinen K, Komi PV. Changes in electrical and mechanical
behavior of leg extensor muscles during heavy resistance strength
training. Scand J Sports Sci. 1985;7:55– 64.
23 Kraemer WJ, Fleck SJ, Evans WJ. Strength and power training:
physiological mechanisms of adaptation. Exerc Sport Sci Rev. 1996;24:
363–397.
24 Aagaard P, Simonsen EB, Andersen JL, et al. Neural adaptation to
resistance training: changes in evoked V-wave and H-reflex responses.
J Appl Physiol. 2002;92:2309 –2318.
25 Andersen LL, Andersen JL, Magnusson SP, Aagaard P. Neuromus-
cular adaptations to detraining following resistance training in previ-
ously untrained subjects. Eur J Appl Physiol. 2005;99:87–94.
26 Hakkinen K, Alen M, Komi PV. Changes in isometric force- and
relaxation-time, electromyographic and muscle fibre characteristics of
human skeletal muscle during strength training and detraining. Acta
Physiol Scand. 1985;125:573–585.
27 Higbie EJ, Cureton KJ, Warren GL III, Prior BM. Effects of
concentric and eccentric training on muscle strength, cross-sectional
area, and neural activation. J Appl Physiol. 1996;81:2173–2181.
28 Hortobagyi T, Barrier J, Beard D, et al. Greater initial adaptations to
submaximal muscle lengthening than maximal shortening. J Appl
Physiol. 1996;81:1677–1682.
29 Moritani T, deVries H A. Neural factors versus hypertrophy in the
time course of muscle strength gain. Am J Phys Med. 1979;58:115–130.
30 Lindahl M. Med Stok Over Sten. Århus, Denmark: Clemenstrykkeriet;
2003.
31 Voss DE, Ionta MK, Myers BJ. Proprioceptive Neuromuscular Facilita-
tion. 3rd ed. Philadelphia, Pa: Harper & Row Publishers; 1985.
32 Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Cham-
paign, Ill: Human Kinetics Inc; 2004.
33 Milner-Brown HS, Stein RB. The relation between the surface
electromyogram and muscular force. J Physiol. 1975;246:549 –569.
34 Moritani T, deVries HA. Reexamination of the relationship between
the surface integrated electromyogram (IEMG) and force of isometric
contraction. Am J Phys Med. 1978;57:263–277.
35 Thorstensson A, Karlsson J, Viitasalo JH, et al. Effect of strength
training on EMG of human skeletal muscle. Acta Physiol Scand. 1976;
98:232–236.
36 Alkner BA, Tesch PA, Berg HE. Quadriceps EMG/force relation-
ship in knee extension and leg press. Med Sci Sports Exerc. 2000;32:
459 – 463.
37 Aratow M, Ballard RE, Crenshaw AG, et al. Intramuscular pressure
and electromyography as indexes of force during isokinetic exercise.
J Appl Physiol. 1993;74:2634 –2640.
38 Kellis E, Baltzopoulos V. The effects of antagonist moment on the
resultant knee joint moment during isokinetic testing of the knee
extensors. Eur J Appl Physiol Occup Physiol. 1997;76:253–259.
696 . Andersen et al
39 Alkjaer T, Simonsen EB, Jorgensen U, Dyhre-Poulsen P. Evaluation
of the walking pattern in two types of patients with anterior cruciate
ligament deficiency: copers and non-copers. Eur J Appl Physiol. 2003;
89:301–308.
40 Kellis E, Baltzopoulos V. The effects of normalization method on
antagonistic activity pattern during eccentric and concentric isokinetic
knee extension and flexion. J Electromyogr Kinesiol. 1996;6:235–245.
41 Rutherford OM, Purcell C, Newham DJ. The human force:velocity
relationship: activity in the knee flexor and extensor muscles before
and after eccentric practice. Eur J Appl Physiol. 2001;84:133–140.
42 Wilk KE, Escamilla RF, Fleisig GS, et al. A comparison of tibiofemo-
ral joint forces and electromyographic activity during open and closed
kinetic chain exercises. Am J Sports Med. 1996;24:518 –527.
43 Fry AC. The role of resistance exercise intensity on muscle fibre
adaptations. Sports Med. 2004;34:663– 679.
44 Kraemer WJ, Adams K, Cafarelli E, et al. American College of Sports
Medicine position stand: progression models in resistance training for
healthy adults. Med Sci Sports Exerc. 2002;34:364 –380.
45 Anderson T, Kearney JT. Effects of three resistance training pro-
grams on muscular strength and absolute and relative endurance. Res
Q Exerc Sport. 1982;53:1–7.
46 Campos GE, Luecke TJ, Wendeln HK, et al. Muscular adaptations in
response to three different resistance-training regimens: specificity of
repetition maximum training zones. Eur J Appl Physiol. 2002;88:50 – 60.
47 Harber MP, Fry AC, Rubin MR, et al. Skeletal muscle and hormonal
adaptations to circuit weight training in untrained men. Scand J Med Sci
Sports. 2004;14:176 –185.
48 Doucette SA, Goble EM. The effect of exercise on patellar tracking
in lateral patellar compression syndrome. Am J Sports Med. 1992;20:
434 – 440.
49 Henry JH. Conservative treatment of patellofemoral subluxation.
Clin Sports Med. 1989;8:261–278.
50 Soderberg GL, Minor SD, Arnold K, et al. Electromyographic
analysis of knee exercises in healthy subjects and in patients with knee
pathologies. Phys Ther. 1987;67:1691–1696.
51 Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrated Guide.
Berlin, Germany: Springer; 2003.
52 Myklebust G, Engebretsen L. Rehabilitation of knee injuries. In:
Bahr R, Maehlum S, eds. Clinical Guide to Sports Injuries. Champaign, Ill:
Human Kinetics Inc; 2004:353–359.
53 Aagaard P, Simonsen EB, Andersen JL, et al. Antagonist muscle
coactivation during isokinetic knee extension. Scand J Med Sci Sports.
2000;10:58 – 67.
54 Hakkinen K, Kallinen M, Izquierdo M, et al. Changes in agonist-
antagonist EMG, muscle CSA, and force during strength training in
middle-aged and older people. J Appl Physiol. 1998;84:1341–1349.
55 Hortobagyi T, Lambert NJ, Hill JP. Greater cross education follow-
ing training with muscle lengthening than shortening. Med Sci Sports
Exerc. 1997;29:107–112.
56 Tesch PA, Dudley GA, Duvoisin MR, et al. Force and EMG signal
patterns during repeated bouts of concentric or eccentric muscle
actions. Acta Physiol Scand. 1990;138:263–271.
57 De Luca CJ. The use of surface electromyography in biomechanics.
J Appl Biomech. 1997;13:135–163.
58 Winter DA. Biomechanics and Motor Control of Human Movement. 2nd
ed. New York, NY: John Wiley & Sons Inc; 1990:11–50.
59 Basmajian J, DeLuca CJ. Muscles Alive: Their Functions Revealed by
Electromyography. Baltimore, Md: Williams & Wilkins; 1985.
Physical Therapy . Volume 86 . Number 5 . May 2006

60 Atha J. Strengthening muscle. Exerc Sport Sci Rev. 1981;9:1–73.
61 Rasch PJ, Morehouse LE. Effect of static and dynamic exercises on
muscular strength and hypertrophy. J Appl Physiol. 1957;11:29 –34.
62 Rutherford OM, Jones DA. The role of learning and coordination
in strength training. Eur J Appl Physiol Occup Physiol. 1986;55:100 –105.
63 Arms SW, Pope MH, Johnson RJ, et al. The biomechanics of
anterior cruciate ligament rehabilitation and reconstruction. Am J
Sports Med. 1984;12:8 –18.
64 Henning CE, Lynch MA, Glick KR Jr. An in vivo strain gage study of
elongation of the anterior cruciate ligament. Am J Sports Med. 1985;13:
22–26.
65 Yack HJ, Collins CE, Whieldon TJ. Comparison of closed and open
kinetic chain exercise in the anterior cruciate ligament-deficient knee.
Am J Sports Med. 1993;21:49 –54.
66 Morrissey MC, Drechsler WI, Morrissey D, et al. Effects of distally
fixated versus nondistally fixated leg extensor resistance training on
knee pain in the early period after anterior cruciate ligament recon-
struction. Phys Ther. 2002;82:35– 43.
67 Hamill BP. Relative safety of weightlifting and weight training.
J Strength Cond Res. 1994;8:53–57.
68 Grana WA, Kriegshauser LA. Scientific basis of extensor mechanism
disorders. Clin Sports Med. 1985;4:247–257.
69 Lieb FJ, Perry J. Quadriceps function: an electromyographic study
under isometric conditions. J Bone Joint Surg Am. 1971;53:749 –758.
70 Reynolds L, Levin TA, Medeiros JM, et al. EMG activity of the vastus
medialis oblique and the vastus lateralis in their role in patellar
alignment. Am J Phys Med. 1983;62:61–70.
71 Fox TA. Dysplasia of the quadriceps mechanism: hypoplasia of the
vastus medialis muscle as related to the hypermobile patella syndrome.
Surg Clin North Am. 1975;55:199 –226.
72 Lindberg U, Lysholm J, Gillquist J. The correlation between arthro-
scopic findings and the patellofemoral pain syndrome. Arthroscopy.
1986;2:103–107.
73 Nagamine R, Otani T, White SE, et al. Patellar tracking measure-
ment in the normal knee. J Orthop Res. 1995;13:115–122.
74 Hanten WP, Schulthies SS. Exercise effect on electromyographic
activity of the vastus medialis oblique and vastus lateralis muscles. Phys
Ther. 1990;70:561–565.
75 Souza DR, Gross MT. Comparison of vastus medialis obliquus:
vastus lateralis muscle integrated electromyographic ratios between
healthy subjects and patients with patellofemoral pain. Phys Ther.
1991;71:310 –316.
Physical Therapy . Volume 86 . Number 5 . May 2006
ўўўўўўўўўўўўўўўўўўўўўў
76 Boucher JP, King MA, Lefebvre R, Pepin A. Quadriceps femoris
muscle activity in patellofemoral pain syndrome. Am J Sports Med.
1992;20:527–532.
77 Cerny K. Vastus medialis oblique/vastus lateralis muscle activity
ratios for selected exercises in persons with and without patellofemoral
pain syndrome. Phys Ther. 1995;75:672– 683.
78 Matheson JW, Kernozek TW, Fater DC, Davies GJ. Electromyo-
graphic activity and applied load during seated quadriceps exercises.
Med Sci Sports Exerc. 2001;33:1713–1725.
79 Voight ML, Wieder DL. Comparative reflex response times of vastus
medialis obliquus and vastus lateralis in normal subjects and subjects
with extensor mechanism dysfunction: an electromyographic study.
Am J Sports Med. 1991;19:131–137.
80 Zakaria D, Harburn KL, Kramer JF. Preferential activation of the
vastus medialis oblique, vastus lateralis, and hip adductor muscles
during isometric exercises in females. J Orthop Sports Phys Ther. 1997;
26:23–28.
81 Francis RS, Scott DE. Hypertrophy of the vastus medialis in knee
extension. Phys Ther. 1974;54:1066 –1070.
82 Speakman HG, Weisberg J. The vastus medialis controversy. Physio-
therapy. 1977;63:249 –254.
83 Gryzlo SM, Patek RM, Pink M, Perry J. Electromyographic analysis
of knee rehabilitation exercises. J Orthop Sports Phys Ther. 1994;20:
36 – 43.
84 Arvidsson I, Arvidsson H, Eriksson E, Jansson E. Prevention of
quadriceps wasting after immobilization: an evaluation of the effect of
electrical stimulation. Orthopedics. 1986;9:1519 –1528.
85 Guo K, Ye Q, Lin J, et al. [Selective training of the vastus medialis
muscle using electrical stimulator for chondromalacia patella]. Zhong-
guo Yi Xue Ke Xue Yuan Xue Bao. 1996;18:156 –160.
86 Aagaard P, Simonsen EB, Magnusson SP, et al. A new concept for
isokinetic hamstring: quadriceps muscle strength ratio. Am J Sports Med.
1998;26:231–237.
87 Heijne A, Fleming BC, Renstrom PA, et al. Strain on the anterior
cruciate ligament during closed kinetic chain exercises. Med Sci Sports
Exerc. 2004;36:935–941.
88 Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of
the anterior cruciate ligament and thigh muscles in maintaining joint
stability. Am J Sports Med. 1987;15:207–213.
Andersen et al . 697