Trunk muscle activation and associated lumbar spine joint shear forces under different levels of external forward force applied to the trunk.

High anterior intervertebral shear loads could cause low back injuries and therefore the neuromuscular system may actively counteract these forces. This study investigated whether, under constant moment loading relative to L3L4, an increased externally applied forward force on the trunk results in a shift in muscle activation towards the use of muscles with more backward directed lines of action, thereby reducing the increase in total joint shear force. Twelve participants isometrically resisted forward forces, applied at several locations on the trunk, while moments were held constant relative to L3L4. Surface EMG and lumbar curvature were measured, and an EMG-driven muscle model was used to calculate compression and shear forces at all lumbar intervertebral joints. Larger externally applied forward forces resulted in a flattening of the lumbar lordosis and a slightly more backward directed muscle force. Furthermore, the overall muscle activation increased. At the T12L1 to L3L4 joint, resulting joint shear forces remained small (less than 200N) because the average muscle force pulled backward relative to those joints. However, at the L5S1 joint the average muscle force pulled the trunk forward so that the increase in muscle force with increasing externally applied forward force caused a further rise in shear force (by 102.1N, SD=104.0N), resulting in a joint shear force of 1080.1N (SD=150.4N) at 50Nm moment loading. It is concluded that the response of the neuromuscular system to shear force challenges tends to increase rather than reduce the shear loading at the lumbar joint that is subjected to the highest shear forces.     

Spinal loads and trunk muscles forces during level walking – A combined in vivo and in silico study on six subjects

During level walking, lumbar spine is subjected to cyclic movements and intricate loading of the spinal discs and trunk musculature. This study aimed to estimate the spinal loads (T12–S1) and trunk muscles forces during a complete gait cycle.Six men, 24–33 years walk barefoot at self-selected speed (4–5 km/h). 3D kinematics and ground reaction forces were recorded using a motion capturing system and two force plates, implemented in an inverse dynamic musculoskeletal model to predict the spinal loads and trunk muscles forces. Additionally, the sensitivity of the intra-abdominal pressure and lumbar segment rotational stiffness was investigated.Peak spinal loads and trunk muscle forces were between the gait instances of heel strike and toe off. In L4–L5 segment, sensitivity analysis showed that average peak compressive, antero-posterior and medio-lateral shear forces were 130–179%, 2–15% and 1–6%, with max standard deviation (±STD) of 40%, 6% and 3% of the body weight. Average peak global muscles forces were 24–55% (longissimus thoracis), 11–23% (iliocostalis thoracis), 12–16% (external oblique), 17–25% (internal oblique) and 0–8% (rectus abdominus) of body weight whereas, the average peak local muscles forces were 11–19% (longissimus lumborum), 14–31% (iliocostalis lumborum) and 12–17% (multifidus). Maximum ± STD of the global and local muscles forces were 13% and 8% of the body weight.Large inter-individual differences were found in peak compressive and trunk muscles forces whereas the sensitivity analysis also showed a substantial variation.     

Tripping Elicits Earlier and Larger Deviations in Linear Head Acceleration Compared to Slipping

Slipping and tripping contribute to a large number of falls and fall-related injuries. While the vestibular system is known to contribute to balance and fall prevention, it is unclear whether it contributes to detecting slip or trip onset. Therefore, the purpose of this study was to investigate the effects of slipping and tripping on head acceleration during walking. This information would help determine whether individuals with vestibular dysfunction are likely to be at a greater risk of falls due to slipping or tripping, and would inform the potential development of assistive devices providing augmented sensory feedback for vestibular dysfunction. Twelve young men were exposed to an unexpected slip or trip. Head acceleration was measured and transformed to an approximate location of the vestibular system. Peak linear acceleration in anterior, posterior, rightward, leftward, superior, and inferior directions were compared between slipping, tripping, and walking. Compared to walking, peak accelerations were up to 4.68 m/s² higher after slipping, and up to 10.64 m/s² higher after tripping. Head acceleration first deviated from walking 100-150ms after slip onset and 0-50ms after trip onset. The temporal characteristics of head acceleration support a possible contribution of the vestibular system to detecting trip onset, but not slip onset. Head acceleration after slipping and tripping also appeared to be sufficiently large to contribute to the balance recovery response.     

Validation of a biodynamic model of pushing and pulling.

Pushing and pulling during manual material handling can increase the compressive forces on the lumbar disc region while creating high shear forces at the shoe-floor interface. A sagittal plane dynamic model derived from previous biomechanical models was developed to predict L5/S1 compressive force and required coefficients of friction during dynamic cart pushing and pulling. Before these predictions could be interpreted, however, it was necessary to validate model predictions against independently measured values of comparable quantities. This experiment used subjects of disparate stature and body mass, while task factors such as cart resistance and walking speed were varied. Predicted ground reaction forces were compared with those measured by a force platform, with correlations up to 0.67. Predicted erector spinae and rectus abdominus muscle forces were compared with muscle forces derived from RMS-EMGs of the respective muscle groups, using a static force build-up regression relationship to transform the dynamic RMS-EMGs to trunk muscle forces. Although correlations were low, this was attributed in part to the use of surface EMG on subjects of widely varied body mass. The biodynamic model holds promise as a tool for analysis of actual industrial pushing and pulling tasks, when carefully applied.     

Elevation and orientation of external loads influence trunk neuromuscular response and spinal forces despite identical moments at the L5–S1 level

A wide range of loading conditions involving external forces with varying magnitudes, orientations and locations are encountered in daily activities. Here we computed the effect on trunk biomechanics of changes in force location (two levels) and orientation (5 values) in 4 subjects in upright standing while maintaining identical external moment of 15 Nm, 30 N m or 45 Nm at the L5–S1. Driven by measured kinematics and gravity/external loads, the finite element models yielded substantially different trunk neuromuscular response with moderate alterations (up to 24% under 45 Nm moment) in spinal loads as the load orientation varied. Under identical moments, compression and shear forces at the L5–S1 as well as forces in extensor thoracic muscles progressively decreased as orientation of external forces varied from downward gravity (90°) all the way to upward (−25°) orientation. In contrast, forces in local lumbar muscles followed reverse trends. Under larger horizontal forces at a lower elevation, lumbar muscles were much more active whereas extensor thoracic muscle forces were greater under smaller forces at a higher elevation. Despite such differences in activity pattern, the spinal forces remained nearly identical (<6% under 45 Nm moment). The published recorded surface EMG data of extensor muscles trend-wise agreed with computed local muscle forces as horizontal load elevation varied but were overall different from results in both local and global muscles when load orientation altered. Predictions demonstrate the marked effect of external force orientation and elevation on the trunk neuromuscular response and spinal forces and questions attempts to estimate spinal loads based only on consideration of moments at a spinal level.     

Effects of an anatomically detailed erector spinae model on L4/L5 disc compression and shear

Biomechanical models utilized for analysis of tasks that load the lumbar spine often predict the resultant moment, disc compression and sometimes shear. Usually the extensor muscular and ligament forces of the lumbar spine are assumed to act 5 cm posterior to a disc centre of rotation. This study has re-examined the generation and pathways of muscular force transmission within the extensor musculature. The effects on L4/L5 disc compression and shear estimates of an anatomically and biomechanically justifiable range of tissue moment arms, lines of force and force generating capacity of muscle, input to a computer model, have been determined. Results indicated that L4/L5 compression estimates could be reduced by up to 35% when the output from a more realistic anatomical model of the erector spinae muscle group was compared with that from the frequently reported and simplified single muscle equivalent with a 5 cm moment arm. The shear force estimates could be altered from more than 500 N (L4 tending to shear anteriorly on L5) to less than 200 N with L4 tending to shear posteriorly on L5. Using the combination of input variables considered by the authors to be most feasible to estimate compression, a single 'equivalent' extensor soft tissue moment arm of 7.5 rather than 5 cm would be needed to equate the compression. This simplification of course, does not accommodate the shear force estimate problem.     

Determination of joint moments with instrumented force shoes in a variety of tasks

Ground reaction forces (GRFs) are often used in inverse dynamics analyses to determine joint loading. These GRFs are usually measured using force plates (FPs). As an alternative, instrumented force shoes (FSs) can be used, which have the advantage over FPs that they do not constrain foot placement. This study tested the FS system in one normal weight subject (77 kg) performing 19 different lifting, pushing and pulling and walking tasks. Kinematics were measured with an optoelectronic system and the GRFs and the positions of the centre of pressure (CoP) were synchronously measured with FPs and FSs. Differences between the outcomes of the two measurement systems (i.e. CoP and GRFs) and the resulting ankle and L5/S1 joint moments were determined at the instant of the peak GRF (DaPF). For most lifting and pushing and pulling tasks, the difference between the FP and FS measurements remained small: GRF DaPF remained below 3% body weight, CoP DaPF remained below 10 mm, ankle moment DaPF remained below 7% of the peak total ankle moment that occurred during normal walking and L5/S1 moment DaPF remained below 7% of the peak total L5/S1 moment that occurred during normal symmetric lifting. More substantial differences were only found in the maximal pushing tasks. For the walking tasks, peak vertical GRFs were somewhat underestimated. However, differences in ankle and L5/S1 moments remained small, i.e. DaPF below 7% of the peak total moment that occurred during normal walking.     

Foraging trip decisions by the streaked shearwater Calonectris leucomelas depend on both parental and chick state

Parents of albatross and shearwater species employ a dual foraging strategy, feeding their chicks quickly in repeated short trips and then restoring their own fuel reserves during longer trips. A decline in parental body condition is believed to trigger longer trips, but chick body condition and age may also play a role. To investigate these factors in the little-studied streaked shearwater Calonectris leucomelas, we monitored the nest attendance of 17 pairs on Mikura Island in 2005 using an automated identification system. We also monitored body mass changes and meal masses of 5 of the 17 pairs using an automated weighing system. Although the birds did not show a clear dual foraging pattern, trip duration varied widely from 1 to 15 days. On average, the birds fed chicks 67.6 g during nighttime meals at 2.74-day intervals. Since meal mass did not depend on trip duration, feeding efficiency (meal mass delivered per unit trip duration) decreased as trip duration increased. Parents accumulated more energy reserves when they took longer trips. Parents appeared likely to initiate longer trips when their body condition declined or chick body condition recovered.     

Applying a follower load delivers realistic results for simulating standing

The exact loads acting on the lumbar spine during standing remain hitherto unknown. It is for this reason that different loads are applied in experimental and numerical studies. The aim of this study was to compare intersegmental rotations, intradiscal pressures and facet joint forces for different loading modes simulating standing in order to ascertain, the results for which loading modes are closest to data measured in vivo.A validated osseoligamentous finite element model of the lumbar spine ranging from L1 to the disc L5–S1, was used. Six load application modes were investigated as to how they could simulate standing. This posture was simulated by applying a vertical force of 500 N at the centre of the L1 vertebral endplate with different boundary conditions, by applying a follower load, and by applying upper body weight and muscle forces. The calculated intersegmental rotations and intradiscal pressures were compared to in vivo values.Intersegmental rotations at one level vary by up to 8° for the different loading modes simulating standing. The overall rotation in the lumbar spine varies between 2.2° and 19.5°. With a follower load, the difference to the value measured in vivo is 3.3°. For all other loading cases studied, the difference is greater than 6.6°. Intradiscal pressures vary slightly with the loading mode. Calculated forces in the facet joints vary between 0 and nearly 80 N.Applying a follower load of 500 N is the only loading mode simulating standing for which the calculated values for intervertebral rotations and intradiscal pressures agreed well with in vivo data from literature.     

Sensitivity of intervertebral joint forces to center of rotation location and trends along its migration path

Translational vertebral motion during functional tasks manifests itself in dynamic loci for center of rotation (COR). A shift of COR affects moment arms of muscles and ligaments; consequently, muscle and joint forces are altered. Based on posture- and level-specific trends of COR migration revealed by in vivo dynamic radiography during functional activities, it was postulated that the instantaneous COR location for a particular joint is optimized in order to minimize the joint reaction forces. A musculoskeletal multi-body model was employed to investigate the hypotheses that (1) a posterior COR in upright standing and (2) an anterior COR in forward flexed posture leads to optimized lumbar joint loads. Moreover, it was hypothesized that (3) lower lumbar levels benefit from a more superiorly located COR.The COR in the model was varied from its initial position in posterior-anterior and inferior-superior direction up to ±6 mm in steps of 2 mm. Movement from upright standing to 45° forward bending and backwards was simulated for all configurations. Joint reaction forces were computed at levels L2L3 to L5S1. Results clearly confirmed hypotheses (1) and (2) and provided evidence for the validity of hypothesis (3), hence offering a biomechanical rationale behind the migration paths of CORs observed during functional flexion/extension movement. Average sensitivity of joint force magnitudes to an anterior shift of COR was +6 N/mm in upright and −21 N/mm in 30° forward flexed posture, while sensitivity to a superior shift in upright standing was +7 N/mm and −8 N/mm in 30° flexion. The relation between COR loci and joint loading in upright and flexed postures could be mainly attributed to altered muscle moment arms and consequences on muscle exertion. These findings are considered relevant for the interpretation of COR migration data, the development of numerical models, and could have an implication on clinical diagnosis and treatment or the development of spinal implants.     

Trunk-Pelvis motions and spinal loads during upslope and downslope walking among persons with transfemoral amputation

Larger trunk and pelvic motions in persons with (vs. without) lower limb amputation during activities of daily living (ADLs) adversely affect the mechanical demands on the lower back. Building on evidence that such altered motions result in larger spinal loads during level-ground walking, here we characterize trunk-pelvic motions, trunk muscle forces, and resultant spinal loads among sixteen males with unilateral, transfemoral amputation (TFA) walking at a self-selected speed both up (“upslope”; 1.06 ± 0.14 m/s) and down (“downslope”; 0.98 ± 0.20 m/s) a 10-degree ramp. Tri-planar trunk and pelvic motions were obtained (and ranges-of-motion [ROM] computed) as inputs for a non-linear finite element model of the spine to estimate global and local muscle (i.e., trunk movers and stabilizers, respectively) forces, and resultant spinal loads. Sagittal- (p = 0.001), frontal- (p = 0.004), and transverse-plane (p < 0.001) trunk ROM, and peak mediolateral shear (p = 0.011) and local muscle forces (p = 0.010) were larger (respectively 45, 35, 98, 70, and 11%) in upslope vs. downslope walking. Peak anteroposterior shear (p = 0.33), compression (p = 0.28), and global muscle (p = 0.35) forces were similar between inclinations. Compared to previous reports of persons with TFA walking on level ground, 5–60% larger anteroposterior and mediolateral shear observed here (despite ∼0.25 m/s slower walking speeds) suggest greater mechanical demands on the low back in sloped walking, particularly upslope. Continued characterization of trunk motions and spinal loads during ADLs support the notion that repeated exposures to these larger-than-normal (i.e., vs. level-ground walking in TFA and uninjured cohorts) spinal loads contribute to an increased risk for low back injury following lower limb amputation.     

Pattern of anterior cruciate ligament force in normal walking

The goal of this study was to calculate and explain the pattern of anterior cruciate ligament (ACL) loading during normal level walking. Knee-ligament forces were obtained by a two-step procedure. First, a three-dimensional (3D) model of the whole body was used together with dynamic optimization theory to calculate body-segmental motions, ground reaction forces, and leg-muscle forces for one cycle of gait. Joint angles, ground reaction forces, and muscle forces obtained from the gait simulation were then input into a musculoskeletal model of the lower limb that incorporated a 3D model of the knee. The relative positions of the femur, tibia, and patella and the forces induced in the knee ligaments were found by solving a static equilibrium problem at each instant during the simulated gait cycle. The model simulation predicted that the ACL bears load throughout stance. Peak force in the ACL (303 N) occurred at the beginning of single-leg stance (i.e., contralateral toe off). The pattern of ACL force was explained by the shear forces acting at the knee. The balance of muscle forces, ground reaction forces, and joint contact forces applied to the leg determined the magnitude and direction of the total shear force acting at the knee. The ACL was loaded whenever the total shear force pointed anteriorly. In early stance, the anterior shear force from the patellar tendon dominated the total shear force applied to the leg, and so maximum force was transmitted to the ACL at this time. ACL force was small in late stance because the anterior shear forces supplied by the patellar tendon, gastrocnemius, and tibiofemoral contact were nearly balanced by the posterior component of the ground reaction.     

Sensitivity of muscle and intervertebral disc force computations to variations in muscle attachment sites

Abstract

The current paper aims at assessing the sensitivity of muscle and intervertebral disc force computations against potential errors in modeling muscle attachment sites. We perturbed each attachment location in a complete and coherent musculoskeletal model of the human spine and quantified the changes in muscle and disc forces during standing upright, flexion, lateral bending, and axial rotation of the trunk. Although the majority of the muscles caused minor changes (less than 5%) in the disc forces, certain muscle groups, for example, quadratus lumborum, altered the shear and compressive forces as high as 353% and 17%, respectively. Furthermore, percent changes were higher in the shear forces than in the compressive forces. Our analyses identified certain muscles in the rib cage (intercostales interni and intercostales externi) and lumbar spine (quadratus lumborum and longissimus thoracis) as being more influential for computing muscle and disc forces. Furthermore, the disc forces at the L4/L5 joint were the most sensitive against muscle attachment sites, followed by T6/T7 and T12/L1 joints. Presented findings suggest that modeling muscle attachment sites based on solely anatomical illustrations might lead to erroneous evaluation of internal forces and promote using anatomical datasets where these locations were accurately measured. When developing a personalized model of the spine, certain care should also be paid especially for the muscles indicated in this work.     

Effect of intervertebral translational flexibilities on estimations of trunk muscle forces,kinematics, loads,and stability

Due to the complexity of the human spinal motion segments, the intervertebral joints are often simulated in the musculoskeletal trunk models as pivots thus allowing no translational degrees of freedom (DOFs). This work aims to investigate, for the first time, the effect of such widely used assumption on trunk muscle forces, spinal loads, kinematics, and stability during a number of static activities. To address this, the shear deformable beam elements used in our nonlinear finite element (OFE) musculoskeletal model of the trunk were either substantially stiffened in translational directions (SFE model) or replaced by hinge joints interconnected through rotational springs (HFE model). Results indicated that ignoring intervertebral translational DOFs had in general low to moderate impact on model predictions. Compared with the OFE model, the SFE and HFE models predicted generally larger L4–L5 and L5–S1 compression and shear loads, especially for tasks with greater trunk angles; differences reached ～15% for the L4–L5 compression, ～36% for the L4–L5 shear and ～18% for the L5–S1 shear loads. Such differences increased, as location of the hinge joints in the HFE model moved from the mid-disc height to either the lower or upper endplates. Stability analyses of these models for some select activities revealed small changes in predicted margin of stability. Model studies dealing exclusively with the estimation of spinal loads and/or stability may, hence with small loss of accuracy, neglect intervertebral translational DOFs at smaller trunk flexion angles for the sake of computational simplicity.     

Predictive equations to estimate spinal loads in symmetric lifting tasks

Response surface methodology is used to establish robust and user-friendly predictive equations that relate responses of a complex detailed trunk finite element biomechanical model to its input variables during sagittal symmetric static lifting activities. Four input variables (thorax flexion angle, lumbar/pelvis ratio, load magnitude, and load position) and four model responses (L4–L5 and L5–S1 disc compression and anterior–posterior shear forces) are considered. Full factorial design of experiments accounting for all combinations of input levels is employed. Quadratic predictive equations for the spinal loads at the L4–S1 disc mid-heights are obtained by regression analysis with adequate goodness-of-fit (R²>98%, p<0.05, and low root-mean-squared-error values compared with the range of predicted spine loads). Results indicate that intradiscal pressure values at the L4–L5 disc estimated based on the predictive equations are in close agreement with available in vivo data measured under similar loadings and postures. Combinations of input (posture and loading) variable levels that yield spine loads beyond the tolerance compression limit of 3400 N are identified using contour plots. Ergonomists and bioengineers, faced with the dilemma of using either complex but more accurate models on one hand or less accurate but simple models on the other hand, have thereby easy-to-use predictive equations that quantifies spinal loads and risk of injury under different occupational tasks of interest.     

Lifting over an obstacle: effects of one-handed lifting and hand support on trunk kinematics and low back loading

Mechanical loading of the low back during lifting is a common cause of low back pain. In this study two-handed lifting is compared to one-handed lifting (with and without supporting the upper body with the free hand) while lifting over an obstacle. A 3-D linked segment model was combined with an EMG-assisted trunk muscle model to quantify kinematics and joint loads at the L5S1 joint. Peak total net moments (i.e., the net moment effect of all muscles and soft tissue spanning the joint) were found to be 10+/-3% lower in unsupported one-handed lifting compared to two-handed lifting, and 30+/-8% lower in supported compared to unsupported one-handed lifting. L5S1 joint forces also showed reductions, but not of the same magnitude (18+/-8% and 15+/-10%, respectively, for compression forces, and 15+/-17% and 11+/-14% respectively, for shear forces). Those reductions of low back load were mainly caused by a reduction of trunk and load moment arms relative to the L5S1 joint during peak loading, and, in the case of hand support, by a support force of about 250 N. Stretching one leg backward did not further reduce low back load estimates. Furthermore, one-handed lifting caused an 6+/-8 degrees increase in lateral flexion, a 9+/-5 degrees increase in twist and a 6+/-6 degrees decrease in flexion. Support with the free hand caused a small further increase in lumbar twisting. It is concluded that one-handed lifting, especially with hand support, reduces L5S1 loading but increases asymmetry in movements and moments about the lumbar spine.     

退行性腰椎滑脱临近节段椎间盘退变和关节突关节角度相关研究

目的:探讨退行性腰椎滑脱(DLS)临近节段椎间盘退变程度和关节突关节角度之间的关系。方法:选取我院2012年6月至2016年6月收治的120例DLS患者作为DLS组,另外选取来我院接受体检的健康者120例作为对照组,选择CT进行关节突关节角和腰椎滑脱度的测量,使用MRI的T2像对椎间盘进行Pfirrmann退变分级。结果:DLS组的各节段关节突关节角度均小于对照组(P0.05);DLS组不同滑脱程度的L2/3、L3/4、L5/S1节段关节突关节角度的比较,差异无统计学意义(P0.05);DLS组L2/3、L3/4、L5/S1节段不同椎间盘退变等级间的滑脱程度无显著性差异(P0.05)。L2/3和L3/4节段不同椎间盘退变程度间关节突关节角度差无显著性差异(P0.05),L5/S1节段不同椎间盘退变程度间关节突关节角度差有统计学差异(P0.05)。结论:退行性腰椎滑脱临近节段关节突关节角度明显小于正常人,且临近节段关节突关节的角度并未随着腰椎滑脱程度的加重而改变,退行性腰椎滑脱患者滑脱临近节段椎间盘退变与关节突关节的矢状化程度无关,但L5/S1关节突关节角度不对称性会影响到同节段椎间盘退变程度。     

A frontal plane model of the lumbar spine subjected to a follower load: implications for the role of muscles

Compression on the lumbar spine is 1000 N for standing and walking and is higher during lifting. Ex vivo experiments show it buckles under a vertical load of 80-100 N. Conversely, the whole lumbar spine can support physiologic compressive loads without large displacements when the load is applied along a follower path that approximates the tangent to the curve of the lumbar spine. This study utilized a two-dimensional beam-column model of the lumbar spine in the frontal plane under gravitational and active muscle loads to address the following question: Can trunk muscle activation cause the path of the internal force resultant to approximate the tangent to the spinal curve and allow the lumbar spine to support compressive loads of physiologic magnitudes? The study identified muscle activation patterns that maintained the lumbar spine model under compressive follower load, resulting in the minimization of internal shear forces and bending moments simultaneously at all lumbar levels. The internal force resultant was compressive, and the lumbar spine model, loaded in compression along the follower load path, supported compressive loads of physiologic magnitudes with minimal change in curvature in the frontal plane. Trunk muscles may coactivate to generate a follower load path and allow the ligamentous lumbar spine to support physiologic compressive loads.     

Comparison of shear forces and ligament loading in the healthy and ACL-deficient knee during gait

The purpose of this study was to predict and explain the pattern of shear force and ligament loading in the ACL-deficient knee during walking, and to compare these results to similar calculations for the healthy knee. Musculoskeletal modeling and computer simulation were combined to calculate ligament forces in the ACL-deficient knee during walking. Joint angles, ground-reaction forces, and the corresponding lower-extremity muscle forces obtained from a whole-body dynamic optimization simulation of walking were input into a second three-dimensional model of the lower extremity that represented the knee as a six degree-of-freedom spatial joint. Anterior tibial translation (ATT) increased throughout the stance phase of gait when the model ACL was removed. The medial collateral ligament (MCL) was the primary restraint to ATT in the ACL-deficient knee. Peak force in the MCL was three times greater in the ACL-deficient knee than in the ACL-intact knee; however, peak force sustained by the MCL in the ACL-deficient knee was limited by the magnitude of the total anterior shear force applied to the tibia. A decrease in anterior tibial shear force was brought about by a decrease in the patellar tendon angle resulting from the increase in ATT. These results suggest that while the MCL acts as the primary restraint to ATT in the ACL-deficient knee, changes in patellar tendon angle reduce total anterior shear force at the knee.