DISABILITY AND REHABILITATION,
6, 265-276
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1995, VOL. 17, NO.
REVIEW
A review of the role of the agonist/antagonist
muscle pairs ratio in rehabilitation
P. CALMELS and P. MINAIREt
Accepted for publication: December 1993
Keywords agonist/antagonist ratio, isokinetics, rehabilitation
Summary
Based on a review of the literature, this article analyses the
application of measurement of the agonist/antagonist ratio of
muscular strength in functional rehabilitation. According to
many authors this ratio constitutes an element of functional
specificity of a joint, but it is subject to numerous factors of
variation: the joint considered, dominance, sex, age, physical
activity and velocity of movement. Despite these various fac-
tors, the ratio may constitute a clinical element in the func-
tional analysis of the joint, providing either an index of the
risk of developing certain traumatic sports lesions, or a guide
control in the modalities of rehabilitation.
Introduction
Several recent studies have suggested the role of an
imbalance in the agonist/antagonist ratio in the
pathogenesis of a disease1 or in the severity of the post-
traumatic or postoperative sequelae of the knee2-' or
ankle.8
Although articular biomechanical studies emphasize
the essential role of the agonist/antagonist pair9 and the
participation of alternating and simultaneously concen-
tric and eccentric muscle contraction of either of the two
agonists, they have less frequently reported the impor-
tance of the ratio of the strength of the agonist muscle
over that of the antagonist. The possibilities of
isokinetic evaluation of muscular strength facilitate this
analysis. Many studies have been conducted, but they
report marked variations in the results, which are
difficult to apply to practical modalities of rehabilita-
tion.
?As previously announced in Disability and Rehabilitation,
1995, 17, I , P. Minaire died in September 1994.
Correspondence to: P. Calmels, Services de RCCducation et
RCadaptation Fonctionnelles, Hopital Bellevue, CHU de
Saint-Etienne, 42055 Saint-Etienne 2, France.
0963-8288/95 $10.00
Rehabilitation is generally designed to develop
muscular reinforcement and recovery of ranges of
movement. Very often, it is essentially focused on the
work of a predominant muscle group in its concentric
action (for example, the quadriceps in flexion-extension
of the knee), while neglecting both the role of the an-
tagonist muscle and the eccentric activity of each of
these muscles. However, this agonist and eccentric ac-
tivity constitutes an element of joint stability'O or
physiological protection against stresses imposed on the
articular cartilage,6 and may prove to be a more effec-
tive method of muscular reinforcement than concentric
work."
On the basis of several personal studiesl2-I4 and a
review of the literature, 1+3*6,9-23it appeared interesting to
study the practical value of the evaluation of this
agonist/antagonist ratio and its application to the adap-
tation of certain classical rehabilitation techniques in
osteoarticular diseases.
Review of the biomechanics
The muscle is the only voluntary support of the joint
in relation to periarticular structures (capsule,
ligaments, etc.). Its action is both activating (or effector)
in the initiation of movement and limiting (or inhibitor)
in its antagonist action. The role of the antagonist dur-
ing joint movement has been studied on numerous occa-
sions. Its cortical activation, simultaneous to that of the
agonist, appears to be associated with various factors
such as sensitivity to stretching, angular position, the
strength developed by the agonist and the velocity of
movement. These factors allow inhibition of the an-
tagonist at the time of initiation of the movement and,
inversely, increased activity at the end of a movement in
order to stop it. 10,15,22,23
It is therefore generally accepted that a certain ratio
exists between the agonist group and the antagonist
group in order to protect the However, it ap-
pears difficult to demonstrate a constant and absolute
0 1995 Taylor & Francis Ltd.
 P. Calmels and P. Minaire
value for this ratio for a given muscle pair or a given in-
dividual, especially as physiological modifications are
observed in the value of muscular strength according to
the type of contraction (isometric, isotonic, isokinetic)2s
or the velocity of m ~ v e m e n t . ~For
~ * ~example,
’ NoseZo
reported that the knee flexor/extensor ratio, classically
evaluated as an average of 0.60, actually varies between
0.43 and 0.93 unhealthy subjects.
Factors of variation in the agonist/antagonist muscular
strength ratio
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Apart from physiological elements, specific factors
related to the population sample, exercise and training
need to be taken into account in functional rehabilita-
tion in order to explain variations in the agonist/an-
tagonist ratio.
THE JOINT
The agonist/antagonist ratio varies according to the
muscle pair activated by the joint. In the knee, in which
For personal use only.
the flexor/extensor ratio is less than 1 and equal to an
average of 0.60,2,3,’X,2R
various studies have shown con-
siderable variations. 1-4.13726-40Fewer studies are
available for other joints, but we have found average
values of 0.9-1 for extensor/flexor ratio of the elbow,14
0.50 to 0.60 for the extensor/flexor ratio of the wrist,12
0.76-0.66 for the flexor/extensor ratio of the hip,2x
0-28-0.32 for the flexor/extensor ratio of the ankle,2s
0-87 for the evertor/invertor ratio of the ankle8,41-43
and lastly, for the shoulder, 0.5 for the adductiodab-
duction ratio, 0.80 for the Aexion/extension ratio and
0.66 for the lateral rotatiodmedial rotation
(Table 1).
However, two elements must be taken into account in
relation to the joint:
(1) The dominance: although it is difficult to deter-
mine its participation,26we believe that this fac-
tor must be taken into account, especially in the
upper limbs. We have found a significant
difference in control subjects,I2 which is more
marked in tennis players and probably at-
tenuated by intensive specific activity of the
dominant limb. This difference was also
demonstrated in basketball players in a study of
the elbow flexors and extensor^.'^ However, not
all of the studies agree on the existence of this
difference related to the dominance of the upper
limb 44.45
The results of studies in the lower limbs also
266
differ. According to Stafford and Grana37 the
dominant limb possesses a significantly lower
hamstring/quadriceps ratio than the non-
dominant limb, regardless of the angular veloci-
ty. Hageman el a1.26reported similar results, ex-
clusively in male subjects, for both concentric
and eccentric contraction. Conversely, other
studies in various population samples failed to
demonstrate any significant difference in the
agonist/antagonist ratio between the dominant
limb and the non-dominant limb.3,5,17,33.34,45,46
(2) The position of the joint must be carefully
specified for certain joints involving bi-articular
muscles,47 as muscular elongation or shortening
varies according to the tension-length ratio and
modifies the strength developed. Worrel ef
have demonstrated that, in the sitting position,
the peak isokinetic torque of the quadriceps and
hamstring muscles, and the ratio between the
two, were higher than those obtained in the
supine position, regardless of the velocity of
movement.
SEX
In a study evaluating the muscular strength of the
wrist flexors and extensors,I2 we demonstrated a
significant difference in the extensor/flexor ratio bet-
ween male and female control subjects not performing
any specific sports motor activity involving the upper
limbs. This finding has also been reported by the
author^.^^.^^,^^ However, for Colliander and T e ~ c h ~ ~
there is no difference in the hamstring/quadriceps ratio
between males and females during concentric or eccen-
tric exercise, regardless of the angular velocity.
AGE
Several studies4’J0 have demonstrated an increase in
the peak torque during growth, followed by a plateau
and a gradual decline with time after reaching
adulthood, particularly in the quadriceps and hamstring
muscles in isokinetic and concentric contractions. In a
study of the knee in 69 subjects between the ages of 5
and 25 years, Gobelet3I demonstrated a decrease in the
hamstring/quadriceps ratio between the ages of 5 and 15
years, followed by a slight increase which remained at a
plateau value until the age of 25 years. The hamstring/
quadriceps ratio subsequently increased with age,
essentially because of the reduction in muscular
strength, predominantly affecting the quadriceps.
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Table 1 Kesults o f thc vari~wsstudies analysing the agonivianragonist rario

Authors Joint Type .f Angulur Totul sarnplr .Mrutr ruiiu;
c.irrlru<.ricin wiucitj pWk
~uryire

Ghena, 1991 Knee ('on. 60"/s 100 subjects 0-55 kO.07

Riodex 8.2000"' FIE I2O"is 18-25 years old 0 . 5 7 ~ 0 . 1 2
College athletes Lcc. bO"/s 0.57 t 0.07
120"/s 0 . 6 5 k0.15

Thomas, 198418 Knee Con. 6O"/s 9i women 0.59 t 0 . I 1

Cybex I1 F/F 230"is Left side,
20-61 years
old 0.81 + O . l l
~ ~ ~~

A u I hors Join1 Type of Angular Sample men Mean rairo; Sample women Mean ratio; Toial sanrple Mean ratio;
contraction uelocily peak peak peak
rorque torque iorque
Alexander, 199028 Knee Con. 30"/s 14 men 0.64 8 women 0.65 22 subjects 0.64
Kin Corn,
22 subjects, F/E 230":s DL and NDL 0.77 DL and NDL 0.85 DL and NDL 0.80
elite sprinters EK. 30°/s 0.63 0.66 0.64
23O"is 0.64 0.69 0.66
Francis and Hoobler,
19872' Knee Con. 60°/s 10 men 0.55 ~ 0 . 0 3 I I women
Cybex 11 + Lido 2, F/E Cybex IZOO/S 0-64+0-03
21 subjects,
12-53 years old 240"is 0 - 5 8 & 0-02 0.59t0.02 0 . 5 9 ? 0.08
non-athleric
subjects Cun. 6O"/S 0-67 f 0-07 0.63%0.05 0.65 k O . 0 7
Lido l20"/s 0.77 kO.03 0.72 f 0.I2 0.741.0.02
~
240"/s 0 - R2 2 0.09 0 79 I 0.02 0.79kO-05 3.
r:
Holmcs. 198433 Knee Con. 60"is 16 inen 0.58 20.09 3 I women 0.55 k0.07
Cybex 11, 47 sub-
a=.
jects. 15-18 years c
old. FIE 18O"is 0.68 2 0-07
recreational sport
Hageman el a l , ,
198826 Knee Con. 60" /s 12 men 0 . 5 9 ? 0.07 13 uonien
K i n Corn,
25 subjects, FIE 180"i s DL and NDI. 0 . 8 3 + 0 . 1 2 DL and NDI
12 men. 13 women,
21-33 years old Ex. 60"/s ? 0.10
0.67 0.65 2 0.12
No intensive sport I80"/5 0~70+0.11 0.71 k 0 . 1 3
Klopfer and Greij,
1988" Knee Con, 300";s 23 men I .02 32 \\omen 0.72
Biodex 8.2000,
5 5 subjects, FiE 330"/s I ' I2 0.81
non-athletes. 19-37
ycars old 360"/s '
I 12 0.83
4K)" /s I ' I4 0.X6
j50';,J I 'OR 0.98
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Authors Joint TYPe Of Angular Sample, Mean ratio; Sample, non- Mean ratio;
contraction velocity dominant peak dominant limb peak
limb torque torque
~- ~

Stafford and Grana,

198437 Knee Con. 90"/s 60 subjects 0 . 6 7 t 0 . 0 9 60 subjects 0.68k0.08
Cybex 11, 60 sub-
jects, 18-24
years old, FIE 18Oo/s 0.73t0.10 0.75i-0.09
college football
olavers 3oO0/s 0.82kO. 12 0.85 k 0 . 0 9

Authors Joint TYPe of Angular Sample, high Mean ratio; Sample, left limb Mean ratio;
COntrUctiOn velocity limb peak peak
torque torque
~

Mangine et a / . , 199036 Knee Con. 60°/s 83 subjects 0.56+0.17 83 subjects 0 . 5 6 k 0.17

Biodex B.2000,
83 subjects F/E 450"/s 0.67 t 0. I8 0.70 k 0.18
Soccer players
national team,
16-26 years old
Grace ei a/., 198432 Knee Con. 6Oo/s 172 men 0.60?0.08 172 men 0.61 k 0 . 0 9
Cybex 11, 172
a
subjects, F/E 240"/s 0.71 kO.10 0.71 k 0 . 1 2
football players,
13-18 years old
~

Authors Joint Type of Angular Sample with Mean ratio; Sample without Mean ratio; a
3
contraction velocity gravity peak gravity peak Q.
correction torque correction rorque

Westing and Seger,

1989'' Knee Con. 60"/s 20 subjects 0 . 4 6 k 0 . 0 7 20 subjects 0.61 i-0.07
Spark system, I2O0/S 0.44 i- 0.07 0.62 i- 0.07
20 subjects, F/E 18O0/S 0.45t_0.07 0.66 k 0.07
women, 22 i- 2.2
years old, 240"/s 0.47 i- 0.08 0.68 k 0.07
physical education 360"/s 0.50 i 0 . 0 9 0.78 ? 0.09
students Eccen. 60"/s 0.55 20.08 0 . 6 6 k 0.09
12O0/s 0.56t0.08 0.68 t 0.09
180"/5 0.57t0.08 0.68t0.09
240"/s 0.58 + 0.07 0.71 i-0.09
360"/s 0.58 I 0.07 0.71 k 0 . 0 9
Authors Joint Type of Angular Total sample, Mean ratio; Sample, IS-24 Mean rario; Sample, 25-34 Mean ratio;
contraction velocity men and peak years old peak yeurs old peak
women torque torque torque
Highgenboten el a / . ,
198814 Knee Con. 50°/s 54 subjects, 0.43 ? O . 10 33 men 0 . 4 2 t 0 . 1 0 21 men 0.45 k 0 . 1 1
men
Kin Com,
127 subjects F/E 73 subjects, 0.42 k 0.08 49 women 0.41 k0.08 24 women 0.44i-0.08
women
54 men, 73 women, Ecc. 5Oo/s 54 subjects, 0.51 t0.15 33 men 0 . 4 9 + 0 . 1 2 21 men 0.55k0.19
men
15-34 years old 73 subjects, 0 . 4 9 k 0.14 49 women 0 . 4 9 k 0 . 1 6 24 women 0.49k0.14
women
 Disabil Rehabil Downloaded from informahealthcare.com by University of Auckland on 12/06/14
Authors Joint Type of Angular Sample,For personal Mean
5 and use ratio; Sample, I5 and 25 Mean ratio;
only.
contraction velocity 10 years old peak years old peak
torque torque
~______ ~ ~~ ~~

Gobelet, 19853' Knee Con. 30"/s 6 subjects 0.74k0.05 11 subjects 0.52 + 0.05
(05 years old) (I5 years old)
Cybex 11,
69 subjects, F/E 10 subjects 0 . 7 0 f 0 . 2 1 23 subjects 0.58f0.07
(10 years old) (25 years old)
64 men, 5 women 30O0/s 6 subjects 0.80f0.19 I 1 subjects 0.77 f 0.09
(05 years old) (I5 years old)
untrained + football
players 10 subjects 0.85 k0.18 23 subjects 0.81 k0.08
5-25 years old (10 years old) (25 years old)
Authors Joinf Type of Angular Sample, Mean ratio; Sample, injured Mean ratio;
contraction velocity uninjured peak side peak
side torque torque
Maclntyre and
Wessel, 1988' Knee Con. 200"/s 12 subjects 0.88k0.15 8 subjects I .02 f 0.23
Kin Com,
20 women, FIE Ecc. control group 0 . 7 3 f 0 . 2 5 with PFPS 0.87 + 0.31
recreational
runners, 15-36
years old
Kannus, 1988' Knee con. Isometric 41 subjects 0.42f0.09 41 subjects 0.46 f0.13
Cybex 11,
41 subjects FIE 6O"/S 0.64 f0.I2 0.68 + 0 - I5
27 men, 14 women,
35+ years old 180°/s 0.78 k0.16 0.88f0.17
ACL insufficient
knee
Kannus, 1988' Knee Con. Isometric 24 subjects 0.43 +O. 1 I 24 subjects 0.50f0.20
Cybex 11,
24 subjects, F/E 60"/s 0.60fO. I 1 0.68 f0.19 8.
10 men, 14 women, 3
33 + 16 years old 180°/s 0.71 f 0 . 1 6 0.79+ 0.25 a
LCL insufficient g.
knee
Kannus, 1989' Knee Con. Isometric 2s subjects 0.4420.12 25 subjects 0.40 f0.15
Cybex I I .
25 subjects, F/E 60"/s 0.60 f 0. I3 0.62 f 0. I5
12 men, 13 women,
35 f I2 years old 18Oo/s 0.75k0.19 0.72 k 0.24
MCL insufficient
knee
Worrell et al., 199I4O Knee Con. 60"/s 16 subjects 0.65 f O . 0 9 16 subjects 0.61 k 0 . 0 9
Kin Com,
16 subjects, F/E 180"/s 0.71 f O . 1 0.66 f 0. I 1
men; highly skilled
athletes, Ecc. 6O"/S 0.51 f 0 . 0 8 0.52 -C 0.I 1
hamstring injury,
20.7 years old 180°/s 0.55 f O . 0 6 0.55f0.10
Calmels et a / . , 199013 Knee con. 30"/s 10 subjects 0.58f0.13 10 subjects 0.76 k 0.09
Cybex I I ,
19 subjects. F/E 120"/s 0.62f0.08 0.74 20.10
7 men, 3 women,
19-73 years old,
fractures of the tibia
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~~ ~~
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Aurhors Join( Type of .4ngulur Sumple. men .Meun rurio; Sample, women Meon rario; Totul sample Mean rurro;
c.onrrtrcrion velocrry peuk peuk peok
torque torque torque

Alexander, 1990'x Hip Con. 30"/s I4 men 0.74 8 women 0.79 22 subjects 0.76
Kin Corn, 180"/s 0.59 0.65 DL and NDL 0.61
22 subjects, FIE EN. 30°/s 0.75 0-74 0.75
elite sprinters 180°/s 0.66 0.65 0.66

Aurhors

Cawthorn et ul.,
I99l4' Ankle Con 160°/s 25 \ubJects I . I6 i 0 . 2
Merac system,
25 subjects, INV/EVE right v d e
8 men, 17 women,
untrained, 17-37
years old
Aurhors Joinr Type of Angulur Sumple, men Meun rurio; Sample, women Meun rurio; Total suinple Meun rurio;
contrrrction velociry peuk peuk peak
roraue roruue roraue

Alexander, 1990" Ankle Con. 30°/s 14 men 0.33 8 women 0.31 22 5ubjects 0.32
Kin Com, 180°/s DL and NDL 0.28 DL and NDL 0.28 DL and NDL 0.28
22 subjectc, DF/PF Ecc. 30"/\ 0.41 0.35 0.38
14 men, 8 women. IRO"/s 0.37 0.33 0.34
elite cprinters
0
3
Aurhors Joint T\pe of Angular Sumple, men Meun rurio; Sample, women Meun rurio; 4
contraction velociry peuk peuk
rorque loryue
~~

Wong er ul. 1984j Ankle Con. 30"/5 21 men 0.87 0.21 23 women 0.81 k 0 . 2 2
Cybex I I ,
44 subjects
(20-37 years old) EVVINV 60"/r right and 0 . 9 0 + 0 . 2 5 right and 0.80 0.20
left \ides left side,
Physical therapy
students 120"'\ 0.8620.20 0 . 8 2 + 0 . I9
Authors Jornr Type of Angulur Sumplr. .Llean rurio; Somple, noti- .Meun rutio;
contruction r.elocrrx domintmr peuk domrnunr limb peuk
limb torqire rorqice
~~ ~

Leslie el UI 1990''
. Ankle Con. 30"/\ DL/O"PI I .26 NDL/O"PF 1.22
Cqbex I I , I2O"Is I 61 1.53
16 subjectc, women, INVIEVE 30"/5 I)L/20 1'1 I I2 NDL/2OoPP 1.32
20-33 yearc old I20"/5 1.37 1.61

Authors Joint Type of A ngiilur Sumplr. .Meun rufio; Sumple, injured Meun rurio;
cnnrrucrion r.e/ociiJ uninjured peuk side peuk
vidr rorque torque

Lentell er UI., 1990' Ankle Con. Isometric 33 $ubjects 1 . I2 3 3 subjects 1 .09

Cybex I I ,
33 subjects, I N V/E VE 30"/s 1.15 1.13
17 men, 16 women,
17-54 year5 old,
chronic lateral
instability
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Authors Joint Type of Angular Sample, Mean ratio; Sample, paraplegics Mean ratio;
contraclion velocity healrhy men peak peak
toraue toraue

Calmels el al., 199214 Elbow Con. 30"/s DL healthy I . 1 f 0.2 DL para 1.1 f0.2
Cybex I 1 FIE NDL healthy .2*0.2 NDL para 1.2f0.4
20 subjects, men 60"/s DL healthy .0&0.1 DL para 1~OfO.l
basketball players NDL healthy .2+0.2 NDL para 1.1k0.5
10 controls, 120°/s DL healthy .O 5 0. I DL para 1.OfO. I
10 paraplegics NDL healthy . I f0 . 4 NDL para 1.1 k 0 . 3
30 years old (21-41) 15Oo/s DL healthy .OfO.I DL para 0.9f0.1
NDL healthy .2&0.5 NDL para 1 . 1 k0.I
~______ ~

Authors Joint Type of Angular Sample, men Mean ratio; Sample, women Mean ratio;
contraction velocity peak peak
toraue toraue
b.
Wrist Con. 30"/s DL 0.58f0.03 DL 0.41 k 0 . 0 4 oa
Calmels et al., 1988'* 0
Cybex 11, NDL 0.54f0.03 NDL 0.44 f 0.04 E.
28 subjects, E/F 120°/s DL 0.61f0.03 DL 0.545 0.03 $
14 men, 14 women NDL 0.49f0.03 NDL 0.41 f 0 . 0 2 3
15 tennis players, 30"/s controls-DL 0.57 L 0.04 controls-DL 0.29 k 0.05 s
13 controls, tennis-DL 0.59f0.05 tennis-DL 0.50+ 0.02 0
3 4 k 9 . 6 years I2Oo/s controls-DL 0.59f0.04 controls-DL 0.44f0.03 E.
old (16-55) tennis-DL 0.64k0.04 tennis-DL 0.35f0.04 9
30"/s controls-NDL 0 . 5 5 kO.03 controls-NDL 0.45 k 0.08
tennis-NDL 0.53 -t0.05 tennis-NDL 0.43 f 0.03
12Oo/s controls-NDL 0.52 f 0.04 controls-NDL 0.40 f 0.03
tennis-NDL 0 . 4 6 k 0.03 tennis-NDL 0.41 f 0 . 0 3
Aurhors Joint Type of Angulur Sample, men Mean ratio; Sample. women Mean ratio;
3x
conrraction velocity peak peak
torque torque

Connely Maddoux
et al., 198945 Shoulder Con. 60"/\ 19 men, DL 0 . 6 3 f 0 . 0 9 19 women, DL 0.70f0.12
Cybex 11, 18O0/S 0.61 + 0 . 1 0 0.64 f 0.09
38 subjects, ER/IR
19 men, 19 women 60"/s NDL 0 . 6 2 f 0 . 0 7 NDL 0~71kO.11
180°/s 0.63 i0.I I 0.68 -t 0.15
40 subjects, Shoulder Con. 180°/s 21 men, DL 0.58+0.12 I9 &omen, DL 0.61 k 0 . 0 9
21 men, 3 4 k 10
years old, AB/AD
19 women, 26 k 6
years old NDL 0 . 6 5 k 0 . 1 3 NDL 0.68+ 0. I9
~~ ~ ~~ ~ ~~

DL: dominant limb; NDL: non-dominant limb; Con.: concentric; Ecc.: eccentric; PFPS: patellofemoral pain syndrome; Para: paraplegics; PF: plantar
flexion; FIE: fleuion/extension; ER/IR: lateral/medial rotation; A B / A D : abduction/adduction; INV/EVE: incersion/eversion; ACL: anterior cruciate
ligament; MCL: medial collateral ligament; LCL: lateral collateral ligament.
 P. Calmels and P. Minaire
FUNCTIONAL SPECIFICITY
Just as the type of physical activity modifies the
historical structure of the m u ~ c l e , ~the
~ Jspecificity
~ of
an exercise or activity also appears to modify the
agonist/antagonist ratio. In the same study concerning
the wrist extensor/flexor ratio,I2 this ratio was found to
be higher in a population of tennis players than in a con-
trol population, with a difference proportional to the
level of tennis training. A similar difference was found
between the elbow flexor/extensor ratio in a paraplegic
population and a control p0pu1ation.l~Other authors
have reported variations in the agonist/antagonist ratio
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as a function of a functional specificity, particularly in
studies of certain population samples performing a
specific sports activity,30 and variations in this ratio
have also been observed in several studies conducted in
specific populations such as American football players,
or even according to their position on the field.33.37
These differences appear to be related to histological
modifications induced by training. 3393s
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VELOCITY OF MOVEMENT AND TYPE OF CONTRACTION
CONSIDERED
It has been clearly demonstrated that the value of
muscular strength varies according to the type of con-
traction, isometric, isotonic or isokinetic, but that there
is a statistically significant correlation between the
various values obtained.25
The many studies concerning measurement of
isokinetic strength, for which numerous protocols have
been validated, show that the peak torque decreases
with increasing velocity of movement .23,25,27*35
The agonist/antagonist ratio is also modified accor-
ding to the velocity of movement. At the knee the
hamstring/quadriceps ratio increases with the velocity
of movement, at least during concentric contraction,
from 0.58 to 0.78 as the velocity increases from 50"/s
to 400"/~.~K a n n u ~ ~reported
,~ various studies
demonstrating an increase in this ratio in the knee in
control subjects, as the isometric or isokinetic measure-
ment at low velocity was about 50% and increased to
100% at an isokinetic velocity of 3 0 O 0 / s . This difference
is reflected by certain functional and histological varia-
tions between these two muscle g r o ~ p s . * -Alexander28
~,~
also demonstrated an increase in this hamstring/
quadriceps ratio, but to a lesser degree, from 0.64 to
0.77, during concentric contraction, and Hageman et
a1.26confirmed this increase in both sexes. Klopfer and
Greij's conducted at very high angular
272
velocities ( 3 O O 0 / s to 450°/s) gave hamstring/quadriceps
ratios greater than 1.
Studying other joints, Alexander28also demonstrated
a decrease in the flexor/extensor ratio in the hip and
ankle with increasing velocity of movement. He at-
tributed this finding to the physical specificity of his
population of sprinters. In reality, the direction of this
variation depends on the ratio considered as, in the
studies by Leslie et al.42 or Lentell et al.x the inver-
tor/evertor ratio of the ankle increased with increasing
angular velocity.
Under conditions of concentric work the variations
observed between different studies could be related to
whether or not a gravity correction was taken into ac-
count, which would induce variations of the order of
8-12V0.~*~~
Few studies are currently available for eccentric work.
Hageman el a1.26in a population of 25 subjects tested at
O"/s and 180°/s during isokinetic contraction, and
Westing and S e g e ~ -studying
,~~ 21 male physical educa-
tion students at angular velocities of 30°/s, 120°/s and
270"/s, demonstrated the absence of any significant in-
crease in the hamstring/quadriceps ratio with velocity
of eccentric movement.
In contrast, this ratio varies, at the same angular
velocity, depending on whether it is analysed under con-
centric or eccentric conditions. The study by Ghena el
al.30concerning the hamstring/quadriceps ratio of 100
sportsmen between the ages of 18 and 25 years, during
concentric and eccentric contraction according to the
isokinetic method at 60"/s and 12Oo/s, showed that this
ratio was higher at an equivalent velocity for eccentric
work than for concentric work. These results are in line
with those reported by Westing and Seger.39
Bearing in, mind that, in general, eccentric muscular
strength is greater than concentric muscular
but that, in contrast, the agonist/an-
tagonist ratio is higher for eccentric work than for con-
centric ~ o r k , this ~ ~ variation
, ~ ~ between concentric
work and eccentric work can be considered to occur in
different proportions between the agonist and the
antagonist.
The agonist/antagonist ratio varies according to the
angle of a n a l y ~ i s and
, ~ most authors calculate a ratio
from the maximal value obtained for the agonist over
the maximal value obtained for the antagonist without
taking this angle into account. This relation with the
angle could be important when the peak torque is com-
pared during concentric and eccentric work. This sug-
gests that it may be preferable to analyse global work
which covers the whcle range of joint movements rather
than the peak torque.
 Agonist/antagonist muscle pairs ratio
In general, although many studies have analysed the
agonist/antagonist ratio (Table l ) , they are often
difficult t o compare, as the population samples vary in
terms of sex (males, females), age, sports activities and
the protocols vary in terms of apparatuses, velocities,
corrections for gravity, analysis of dominance or non-
dominance of the limb tested and the possible presence
of lesions and, lastly, the expression of the results also
differs, with or without means and with standard devia-
tions or standard errors of the mean.
Disabil Rehabil Downloaded from informahealthcare.com by University of Auckland on 12/06/14
Value of the agonist/antagonist ratio
Although only a few studies have directly evaluated
the agonist/antagonist ratio in rehabilitation, it seemed
useful t o analyse several studies referring to this ratio,
either as an initial factor in the development of certain
diseases or as an element of follow-up after surgery or
rehabilitation in relation to certain functional sequelae,
as the agonist/antagonist muscle pair may represent a
necessary equilibrium for normal joint f ~ n c t i o n . ~ , ~ ~ structures
In 1984, in a randomized study of 172 football
For personal use only.
players, Grace et ~ 7 1 investigated
.~~ the existence of a
relationship between the presence of an imbalance of
muscular strength of the knee and the development of
lesions of this joint during the sports season. The results
failed to demonstrate any relationship between the
development of a lesion and the presence of a muscular
imbalance analysed at various angular velocities, even
when comparing the values for the hamstr-
ing/quadriceps ratio. Grace et al. therefore concluded
that measurement of a muscular imbalance between the
two limbs did not constitute a primordial risk factor for
the development of lesions. The recent study by Worrel
et al.40evaluating the isokinetic strength and extensibili-
ty of the hamstring muscles in a population of athletes
with hamstring lesions in comparison with an equivalent
population of healthy athletes, did not show any
difference in the hamstring/quadriceps ratio at 60'1s or
180°/s, but revealed a correlation with a lack of
extensibility.
In a study of a group of 20 females between the ages
of 15 and 36 years, composed of 12 control subjects and
eight subjects with a clinical femoropatellar syndrome,
MacIntyre and Wessel looked for a significant modifica-
tion in the hamstring/quadriceps ratio. Each subject
was tested with a Kin Corn isokinetic dynamometer dur-
ing concentric and eccentric contraction at an angular
velocity of 2OO0/s. The results did not
demonstrate any significant modification in the ham-
string/quadriceps ratio for either concentric or eccentric
contraction. However, this study confirmed the ex-
istence of a difference in the peak torque between eccen-
tric and concentric contraction in the two population
groups, as had already been reported by Komi."
However, according to this author, this difference bet-
ween the two types of contraction is not of the same
order of magnitude for the quadriceps as for the
hamstrings: the eccentric muscular strength couple of
the hamstrings increases to a lesser degree in relation to
concentric contraction than does the quadriceps. These
findings, revealing a different concentric-eccentric rela-
tion between the hamstrings and the quadriceps, are
similar to those reported by Ghena et based on a
more precise analysis of the variations in the eccentric
strength in relation to the concentric couple, as a func-
tion of the muscle studied.
Many studies have investigated the significance of the
hamstring/quadriceps ratio in the knee joint, particular-
ly in the presence of cruciate ligament lesions. Accor-
ding to Solomonow and co-workers,6v22 there is a
synergy between the musculature and the periarticular
, ~ ~ , ~ ~responsible for joint integrity. The antagonist
muscles appear to constitute a 'regulator' in response to
various stresses. They reported the study by Renstrom et
~ 1who . demonstrated
~ ~ the role of the hamstrings which
tend to decrease the tension exerted on the anterior
cruciate ligament as a result of their co-contraction with
the quadriceps. According to Grabiner et a1.16 this role
of the hamstrings varies according to the type of
isometric or isokinetic contraction in healthy or injured
knees. Similarly, 'cruciate ligament-hamstring reflex
arc' may exist, according to Solomonow el
However, Baratta et ~ 7 1 . 'suggested
~ that specific train-
ing, particularly of certain athletes, with muscular rein-
forcement of the agonist (quadriceps), would be respon-
sible for inhibition of co-activation of the antagonist,
associated with a high risk of lesions to the cruciate liga-
ment, and certain clinical s t ~ d i e s . ~recommend
, ~ ~ , ~ ~ ear-
ly training of the hamstrings for athletes presenting with
anterior cruciate ligament lesions. This training would
help to limit the stresses during rotation of the knee, and
should be associated with endurance exercises in order
to support articular stresses which increase with
tiredness.
In a clinical study of anterior cruciate lesions, Kan-
nus3 looked for an anomaly of the ham-
string/quadriceps ratio in 41 subjects and established a
correlation between the measurements of strength and a
standardized clinical assessment. He did not find any
significant difference in the agonist/antagonist ratio bet-
ween healthy and injured knees, considering a ratio of
50% to 80% as a normal absolute value. However, he
27 3
 P. Calmels and P. Minaire
found that the subjects with the lowest score on the
Lysholm Knee Scoring Scale used for the clinical assess-
ment demonstrated a difference in the agonist/an-
tagonist ratio between the healthy side and the injured
side greater than 15%. According to this author, the
value of the contralateral ratio therefore constitutes the
parameter most closely correlated to the reduction in
functional signs.
We conducted a study of the muscular deficit after im-
mobilization for leg fractures in a population of 10 sub-
jects presenting functional signs of knee instability after
an average of 4 - 5 months of rehabilitation after the in-
Disabil Rehabil Downloaded from informahealthcare.com by University of Auckland on 12/06/14
itial accident.') We observed the persistence of a deficit
in the peak torque if the quadriceps and hamstrings on
the injured side, but a significant increase in the hamstr-
inglquadriceps ratio on the injured side compared to
the healthy side. These results suggested independent
modifications in muscular strength between the two
muscle groups, even away from the lesion and despite
intensive rehabilitation. Each of these muscle groups
possesses a functional specificity, either more static or
more dynamic, which is well analysed by the isokinetic
For personal use only.
method. This study confirmed that the agonist/an-
tagonist ratio on the healthy side constitutes a good in-
dicator for the agonistlantagonist muscle balance of an
injured joint.
Lentell et al.,* conducted a study in patients with
chronic instability of the ankle, looking for muscular
alterations in the injured ankle compared to the healthy
contralateral ankle. In a population of 33 subjects, bet-
ween the ages of 17 and 54 years, they analysed the
isometric and isokinetic peak torque at 30°/s of the
ankle invertors and evertors on both sides. They found
no significant difference in muscular strength, regardless
of the angular velocity, between the two sides, but a
slight difference in the evertor/invertor ratio. However,
55% of the subjects demonstrated an imbalance bet-
ween the injured side and the healthy side. As suggested
by the authors, although it would be useful to confirm
the hypothesis of a muscular imbalance in this popula-
tion of subjects presenting with chronic ankle instabili-
ty, a test performed at higher angular velocities, testing
the capacities of explosive response of the muscles,
would appear to be more suitable for analysing a disease
in which proprioception plays an important role.
These various studies demonstrate the value of
analysis of the agonist/antagonist ratio, as well as the
difficulties of this evaluation. Isokinetic analysis pro-
vides valuable information not only concerning the
muscular strength, but also concerning the functional
specificity of a muscle based on analyses at different
velocities. Concentric and, more recently, eccentric
274
evaluations, despite the difficulties at high velocities, ap-
pear to be ideal.
Practical applications in rehabilitation
We believe that this agonist/antagonist ratio, which is
now easier to measure and more reliable as a result of
isokinetic studies, may be useful in rehabilitation. When
this ratio is taken into account:
(1) It provides an indicator of the agonist/an-
tagonist muscle groups of a joint, bearing in
mind that it appears to be specific for each in-
dividual and each joint.9
(2) It establishes an index of dynamic muscular ac-
tivity; depending on its variation at different
velocities of movement, it can demonstrate the
more static or more explosive nature of one of
the muscle groups and can consequently define
the predominant histological composition of
slow or rapid fibres.52
(3) It represents an individual reference, at least for
the lower limb. In comparison with the con-
tralateral healthy limb it constitutes a measurable
parameter which can be used as a treatment ob-
jective and to establish a rehabilitation
programme. 3*4,54
In conclusion, although few studies have examined
this subject, measurement of the agonist/antagonist
ratio appears to be very useful in the functional assess-
ment of a joint. This index may be a good indicator of
imbalance of joint mechanisms, and may allow a
pathophysiological approach to certain osteoarticular
diseases. Although certain parameters have yet to be
defined, this ratio also constitutes a way of analysing
certain post-traumatic or postoperative functional se-
quelae for the purposes of rehabilitation.
New dynamometric tools for measuring concentric
and eccentric torques should enable us to more ac-
curately evaluate and associate, as required, muscular
reinforcement, recovery of the range of joint
movements and sensorimotor restoration of a joint.
Acknowledgement
This work was supported by The Center for Exercise Studies (GIP
Exercice) incorporating: University Jean Monnet, National Medical
Research Institute (INSERM), Ministry of Sports and Education, University
Claude Bernard-Lyon I ,
 ARonist/antagonist muscle pairs ratio
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