Achilles tendon stress is more sensitive to subject-specific geometry than subject-specific material properties: A finite element analysis

This study used subject-specific measures of three-dimensional (3D) free Achilles tendon geometry in conjunction with a finite element method to investigate the effect of variation in subject-specific geometry and subject-specific material properties on tendon stress during submaximal isometric loading. Achilles tendons of eight participants (Aged 25–35 years) were scanned with freehand 3D ultrasound at rest and during a 70% maximum voluntary isometric contraction. Ultrasound images were segmented, volume rendered and transformed into subject-specific 3D finite element meshes. The mean (±SD) lengths, volumes and cross-sectional areas of the tendons at rest were 62 ± 13 mm, 3617 ± 984 mm³ and 58 ± 11 mm² respectively. The measured tendon strain at 70% MVIC was 5.9 ± 1.3%. Subject-specific material properties were obtained using an optimisation approach that minimised the difference between measured and modelled longitudinal free tendon strain. Generic geometry was represented by the average mesh and generic material properties were taken from the literature. Local stresses were subsequently computed for combinations of subject-specific and generic geometry and material properties. For a given geometry, changing from generic to subject-specific material properties had little effect on the stress distribution in the tendon. In contrast, changing from generic to subject-specific geometry had a 26-fold greater effect on tendon stress distribution. Overall, these findings indicate that the stress distribution experienced by the living free Achilles tendon of a young and healthy population during voluntary loading are more sensitive to variation in tendon geometry than variation in tendon material properties.     

Effects of submaximal and maximal long-lasting contractions on the compliance of vastus lateralis tendon and aponeurosis in vivo

The present study investigated the effects of submaximal sustained and maximal repetitive contractions on the compliance of human vastus lateralis (VL) tendon and aponeurosis in vivo using two different fatiguing protocols. Twelve male subjects performed three maximum voluntary isometric contractions (MVC) of the knee extensors before and after two fatiguing protocols on a dynamometer. The first fatiguing protocol consisted of a long-lasting sustained isometric knee extension contraction at 25% MVC until failure (inability to hold the defined load). The second fatiguing protocol included long-lasting isokinetic (90°/s) knee extension contractions, where maximum moment was exerted and failure was proclaimed when this value fell below 70% of unfatigued maximum isokinetic moment. Ultrasonography was used to determine the elongation and strain of the VL tendon and aponeurosis. Muscle fatigue was indicated by a significant decrease in maximum resultant knee extension moment (p < 0.05) observed during the MVCs after both long-lasting contractions. No significant (p > 0.05) differences in elongation and strain of the VL tendon and aponeurosis were found, when compared every 300 N (tendon force) before and after the fatiguing protocols. The present data indicate, that the VL tendon and aponeurosis in vivo do not suffer from changes in the compliance neither after long-lasting static mechanical loading (strain ～3.2%) nor after long-lasting cyclic mechanical loading (strain 6.2–5.5%).     

Mechanical properties of the patellar tendon in adults and children

It is not currently known how the mechanical properties of human tendons change with maturation in the two sexes. To address this, the stiffness and Young's modulus of the patellar tendon were measured in men, women, boys and girls (each group, n=10). Patellar tendon force (F_pt) was calculated from the measured joint moment during a ramped voluntary isometric knee extension contraction, the antagonist knee extensor muscle co-activation quantified from its electromyographical activity, and the patellar tendon moment arm measured from magnetic resonance images. Tendon elongation was imaged using the sagittal-plane ultrasound scans throughout the contraction. Tendon cross-sectional area was measured at rest from ultrasound scans in the transverse plane. Maximal F_pt and tendon elongation were (mean±SE) 5453±307 N and 5±0.5 mm for men, 3877±307 N and 4.9±0.6 mm for women, 2017±170 N and 6.2±0.5 mm for boys and 2169±182 N and 5.9±0.7 mm for girls. In all groups, tendon stiffness and Young's modulus were examined at the level that corresponded to the maximal 30% of the weakest participant's F_pt and stress, respectively; these were 925–1321 N and 11.5–16.5 MPa, respectively. Stiffness was 94% greater in men than boys and 84% greater in women than girls (p<0.01), with no differences between men and women, or boys and girls (men 1076±87 N/mm; women 1030±139 N/mm; boys 555±71 N/mm and girls 561.5±57.4 N/mm). Young's modulus was 99% greater in men than boys (p<0.01), and 66% greater in women than girls (p<0.05). There were no differences in modulus between men and women, or boys and girls (men 597±49 MPa; women 549±70 MPa; boys 255±42 MPa and girls 302±33 MPa). These findings indicate that the mechanical stiffness of tendon increases with maturation due to an increased Young's modulus and, in females due to a greater increase in tendon cross-sectional area than tendon length.     

Contraction intensity and sex differences in knee-extensor fatigability

Females are less fatigable than males during isometric contractions across various muscles and intensities. However, sex differences in knee-extensor fatigability remain relatively unexplored. Purpose: To determine the sex difference in performance fatigability for intermittent, isometric contractions of the knee-extensor muscles. Methods: Eighteen participants (10 males, 8 females) performed intermittent, isometric, knee-extensor contractions at 30% of their maximal voluntary force (MVC) for 30 min and in a separate session at 50% MVC until task-failure. During both fatiguing protocols a MVC was performed every 60 s and electromyography (EMG) was recorded during all contractions. Results: At task completion males had a larger reduction in MVC force for the 30% MVC task (−32 ± 15% vs. −15 ± 16%, P = 0.042) and the 50% MVC task (−34 ± 8% vs. −24 ± 1%, P = 0.045). Furthermore, for the 50% MVC task, females had a longer task duration (937 ± 525 s vs. 397 ± 153 s, P = 0.007). The rise in EMG activity and force fluctuations were more rapid for the males than females (P < 0.05). When participants were matched for strength post hoc (n = 10), a sex difference in fatigability for both tasks was still evident. Conclusions: Females were less fatigable than males during intermittent, isometric, knee-extensor contractions at moderate relative forces and this difference was independent of strength.     

Biceps femoris and semitendinosus tendon/aponeurosis strain during passive and active (isometric) conditions

The purpose of this study was to quantify strain and elongation of the long head of the biceps femoris (BFlh) and the semitendinosus (ST) tendon/aponeurosis. Forty participants performed passive knee extension trials from 90° of knee flexion to full extension (0°) followed by ramp isometric contractions of the knee flexors at 0°, 45° and 90° of knee flexion. Two ultrasound probes were used to visualize the displacement of BFlh and ST tendon/aponeurosis. Three-way analysis of variance designs indicated that: (a) Tendon/aponeurosis (passive) elongation and strain were higher for the BFlh than the ST as the knee was passively extended (p < 0.05), (b) contraction at each angular position was accompanied by a smaller BFlh tendon/aponeurosis (active) strain and elongation than the ST at higher levels of effort (p < 0.05) and (c) combined (passive and active) strain was significantly higher for the BFlh than ST during ramp contraction at 0° but the opposite was observed for the 45° and 90° flexion angle tests (p < 0.05). Passive elongation of tendon/aponeurosis has an important effect on the tendon/aponeurosis behavior of the hamstrings and may contribute to a different loading of muscle fibers and tendinous tissue between BFlh and ST.     

History dependence of the electromyogram: Implications for isometric steady-state EMG parameters following a lengthening or shortening contraction

Residual force enhancement (RFE) and force depression (FD) refer to an increased or decreased force following an active lengthening or shortening contraction, respectively, relative to the isometric force produced at the same activation level and muscle length. Our intent was to determine if EMG characteristics differed in the RFE or FD states compared with a purely isometric reference contraction for maximal and submaximal voluntary activation of the adductor pollicis muscle. Quantifying these alterations to EMG in history-dependent states allows for more accurate modeling approaches for movement control in the future. For maximal voluntary contractions (MVC), RFE was 6–15% (P < 0.001) and FD was 12–19% (P < 0.001). The median frequency of the EMG was not different between RFE, FD and isometric reference contractions for the 100% and 40% MVC intensities (P > 0.05). However, root mean square EMG (EMG_RMS) amplitude for the submaximal contractions was higher in the FD and lower in the RFE state, respectively (P < 0.05). For maximal contractions, EMG_RMS was lower for the FD state but was the same for the RFE state compared to the isometric reference contractions (P > 0.05). Neuromuscular efficiency (NME; force/EMG) was lower in the force depressed state and higher in the force enhanced state (P < 0.05) compared to the isometric reference contractions. EMG spectral properties were not altered between the force-enhanced and depressed states relative to the isometric reference contractions, while EMG amplitude measures were.     

Innervation zone shift at different levels of isometric contraction in the biceps brachii muscle

Experiments were carried out to examine whether innervation zone (IZ) location remains stable at different levels of isometric contraction in the biceps brachii muscle (BB), and to determine how the proximity of the IZ affects common surface electromyography (sEMG) parameters. Twelve subjects performed maximal (MVC) and submaximal voluntary isometric contractions at 10%, 20%, 30%, 40%, 50% and 75% of MVC. sEMG signals were recorded with a 13 rows × 5 columns grid of electrodes from the short head of BB. The IZ shifted in the proximal direction by up to 2.4 cm, depending upon the subject and electrode column. The mean shift of all the columns was 0.6 ± 0.4 cm (10% vs. 100% MVC, P < 0.001). This shift biased the average values of mean frequency (+21.8 ± 9.9 Hz, P < 0.001), root mean square (?0.16 ± 0.15 mV, P < 0.05) and conduction velocity (?1.15 ± 0.93 m/s, P < 0.01) in the channels immediately proximal to the IZ. The shift in IZ could be explained by shortening of the muscle fibers, and thus lengthening of the (distal) tendon due to increasing force. These results underline the importance of individual investigation of IZ locations before the placement of sEMG electrodes, even in isometric contractions.     

Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain

The purpose of the current study in combination with our previous published data (Arampatzis et al., 2007) was to examine the effects of a controlled modulation of strain magnitude and strain frequency applied to the Achilles tendon on the plasticity of tendon mechanical and morphological properties. Eleven male adults (23.9±2.2 yr) participated in the study. The participants exercised one leg at low magnitude tendon strain (2.97±0.47%), and the other leg at high tendon strain magnitude (4.72±1.08%) of similar frequency (0.5 Hz, 1 s loading, 1 s relaxation) and exercise volume (integral of the plantar flexion moment over time) for 14 weeks, 4 days per week, 5 sets per session. The exercise volume was similar to the intervention of our earlier study (0.17 Hz frequency; 3 s loading, 3 s relaxation) allowing a direct comparison of the results. Before and after the intervention ankle joint moment has been measured by a dynamometer, tendon–aponeurosis elongation by ultrasound and cross-sectional area of the Achilles tendon by magnet resonance images (MRI). We found a decrease in strain at a given tendon force, an increase in tendon–aponeurosis stiffness and tendon elastic modulus of the Achilles tendon only in the leg exercised at high strain magnitude. The cross-sectional area (CSA) of the Achilles tendon did not show any statistically significant (P>0.05) differences to the pre-exercise values in both legs. The results indicate a superior improvement in tendon properties (stiffness, elastic modulus and CSA) at the low frequency (0.17 Hz) compared to the high strain frequency (0.5 Hz) protocol. These findings provide evidence that the strain magnitude applied to the Achilles tendon should exceed the value, which occurs during habitual activities to trigger adaptational effects and that higher tendon strain duration per contraction leads to superior tendon adaptational responses.     

Ultrasonographic quantification of architectural response in tibialis anterior to neuromuscular electrical stimulation

While muscle contraction in voluntary efforts has been widely investigated, little is known about contraction during neuromuscular electrical stimulation (NMES). The aim of this study was to quantify in vivo muscle architecture of agonist and antagonist muscles at the ankle joint during NMES. Muscle fascicle lengths and pennation angles of the tibialis anterior (TA) and lateral gastrocnemius muscles were assessed via ultrasonography in 8 healthy young males. Measures were obtained during maximal NMES and torque-matched voluntary dorsiflexion contractions. In the TA, NMES induced a shorter fascicle length (67.2 ± 8.1 mm vs 74.6 ± 11.4 mm; p = 0.04) and a greater pennation angle (11.0 ± 2.4° vs 9.3 ± 2.5°; p = 0.03) compared with voluntary torque-matched dorsiflexion contractions. Architectural responses in the antagonist lateral gastrocnemius muscle did not significantly differ from rest or between voluntary and electrically induced contractions (p > 0.05). Contraction of the antagonist muscle was not a contributing factor to a greater fascicle shortening and increased pennation angle in the TA during NMES. TA architectural response during NMES likely arose from the contribution of muscle synergists during voluntary contractions coupled with a potentially localized contractile activity under the stimulation electrodes during NMES induced contractions.     

Impaired action potential conduction at high force levels after eccentric exercise

High-density surface electromyography was used to examine whether gross sarcolemmal function is impaired in m. biceps brachii after intensive eccentric elbow flexor exercise, when measured at wide range of isometric contraction levels.Root mean square (RMS), mean power frequency (MNF) and mean muscle fibre conduction velocity (CV) were calculated before and up to four days post-exercise.Maximal isometric voluntary (MVC) force decreased by 21.3 ± 5.6% two hours after exercise, and by 12.6 ± 11.1% two days post-exercise. CV and MNF decreased both during MVC (CV from 4.1 ± 0.3 m/s to 3.8 ± 0.4 m/s and MNF from 92.6 ± 10 Hz to 85.2 ± 11 Hz) and during electrically evoked maximal M-wave (CV from 4.1 ± 0.3 m/s to 3.0 ± 0.5 m/s and MNF from 97.1 ± 27.2 Hz to 78.0 ± 24.4 Hz) two hours post-exercise. Furthermore, at submaximal isometric force levels, CV and MNF decreased only at higher contraction levels (40%, 50% and 75% of MVC) two hour post-exercise.It can be concluded that intensive exercise can temporarily impair gross sarcolemmal function. In addition, since this only occurred at high force levels, based on Henneman’s size principle, it seems that higher threshold motor units were predominantly affected.     

Biceps brachii myoelectric and oxygenation changes during static and sinusoidal isometric exercises

Surface myoelectric signal changes occurring during sustained isometric contractions have been extensively studied with quantitative surface electromyography (sEMG) and are described by means of some sEMG global variables in time and frequency domain (such as the median power spectral frequency). Recently, the possibility of studying local muscle O₂ saturation during exercise using non-invasive methods has been enhanced thanks to the use of near-infrared spectroscopy (NIRS). The purpose of this work was to combine NIRS and sEMG techniques to analyze the relationship between modifications of sEMG parameters and the underlying metabolic status of the exercising biceps brachii muscle. This relationship was tested under different isometric contraction modalities, namely static (ST) at 20, 40, 60 and 80%MVC and sinusoidal (SIN) at 40 ± 20 and 60 ± 20%MVC. Results clearly indicated the presence of an initial fast phase of muscle O₂ desaturation followed by a slow phase, regardless of the contraction modality. Moreover, the initial rate of muscle O₂ desaturation was related to the level of force output (R = 0.92), but it was independent on the contraction modality (p < 0.05). Similarly, changes in sEMG parameters were related to force level (Conduction Velocity-CV vs. Force: R = 0.87; sEMG Median Frequency-MDF vs. Force: R = 0.86). The high correlation found between CV-MDF and Tissue Oxygenation Index (TOI) slope (R = 0.73 and 0.72, respectively) suggests a strong relationship between NIRS and sEMG data. This study indicates that muscle O₂ demand during isometric contractions from low to high force levels is influenced by the type of active motor units and not from the type of isometric exercise modality.     

Ultrashort echo time T21 values decrease in tendons with application of static tensile loads

In early stages of tendon disease, mechanical properties may become altered prior to changes in morphological anatomy. Ultrashort echo time (UTE) magnetic resonance imaging (MRI) can be used to directly detect signal from tissues with very short T2 values, including unique viscoelastic tissues such as tendons. The purpose of this study was to use UTE sequences to measure T2¹, T1 and magnetization transfer ratio (MTR) variations of tendon samples under static tensile loads. Six human peroneal tendons were imaged before and under static loading using UTE sequences on a clinical 3 T MRI scanner. Tendons were divided into two static tensile loading groups: group A that underwent one-step loading (15 N) and group B that underwent two-step loading (15 and 30 N). The T2¹, T1 and MTR variations were investigated in two selected section regions of interest (ROIs), including whole and core sections. Mean T2¹ values for the first step of loading (groups A and B) in both whole section and core section ROIs were significantly decreased by 13 ± 7% (P = 0.028) and 16 ± 5% (P = 0.017), respectively. For the second loading step (group B), there was a consistent, but non-significant reduction in T2¹ value by 9 ± 2% (P = 0.059) and 7 ± 5% (P = 0.121) for whole and core sections, respectively. Mean T1 did not show any consistent changes for either loading steps (P > 0.05). Mean MTR increased slightly, but not significantly for both loading steps (P > 0.05). Significant differences were found only in T2¹ values of tendons by static tensile load application. Therefore, T2¹ monitoring during loading is suggested for quantitative investigation of the tendons biomechanics.     

Quadriceps function assessment using an incremental test and magnetic neurostimulation: A reliability study

We investigated the reliability of a test assessing quadriceps strength, endurance and fatigability in a single session. We used femoral nerve magnetic stimulation (FMNS) to distinguish central and peripheral factors of neuromuscular fatigue. We used a progressive incremental loading with multiple assessments to limit the influence of subject’s cooperation and motivation.Twenty healthy subjects (10 men and 10 women) performed the test on two different days. Maximal voluntary strength and evoked quadriceps responses via FMNS were measured before, after each set of 10 submaximal isometric contractions (5-s on/5-s off; starting at 10% of maximal voluntary strength with 10% increments), immediately and 30 min after task failure.The test induced progressive peripheral (41 ± 13% reduction in single twitch at task failure) and central fatigue (3 ± 7% reduction in voluntary activation at task failure). Good inter-day reliability was found for the total number of submaximal contractions achieved (i.e. endurance index: ICC = 0.83), for reductions in maximal voluntary strength (ICC > 0.81) and evoked muscular responses (i.e. fatigue index: ICC > 0.85). Significant sex-differences were also detected.This test shows good reliability for strength, endurance and fatigability assessments. Further studies should be conducted to evaluate its feasibility and reliability in patients.     

In vivo moment generation and architecture of the human plantar flexors after different shortening–stretch cycles velocities

The purpose of this study was to examine the moment generation of the human plantar flexors and the architecture of the gastrocnemius medialis muscle during and after shortening–stretch cycles in vivo. Fourteen male subjects (30 ± 7 years, 177 ± 7 cm, 80 ± 9 kg) performed a series of electro-stimulated shortening–stretch plantar flexion contractions. The shortening–stretch cycles were performed at three constant angular velocities (25°/s, 50°/s, 100°/s), two amplitudes (15° and 25° ankle angle changes) and at two different stimulation frequencies (30 Hz and 85 Hz). The resultant ankle joint moments were calculated through inverse dynamics. Pennation angle and fascicle length of the m. gastrocnemius medialis at rest and during contractions were measured using ultrasonography. The corresponding ankle moments, kinematics and changes in muscle architecture were analysed at seven time intervals. A three-way analysis of variance (amplitude × velocity × stimulation frequency) and post-hoc test with Bonferroni correction were used to check the amplitude, velocity and stimulation level related effects on moment enhancement (α = 0.05). The results show an ankle joint moment enhancement after shortening–stretch cycles influenced by muscle architectural changes. We found 2–3% isometric ankle joint moment enhancement at steady state, 1.5–2.0 s after the shortening–stretch cycle. However, the observed alteration in muscle architecture after the imposed perturbation, could lead to an underestimation (1–3%) of joint moment enhancement due to the force–length relationship of the triceps surae. Furthermore, the enhancement observed was independent of the shortening–stretch amplitude, velocity and stimulation frequency.     

Test–retest reliability of the soleus H-reflex is affected by joint positions and muscle force levels

The purpose of this study was to determine the test–retest reliability of the soleus (SOL) H-reflex during rest and isometric contractions at 10%, 30%, and 50% of the maximal voluntary force (MVC) at the ankle joint angles of neutral (0°), plantarflexion (20°), and dorsiflexion (?20°) respectively, in a sitting position. Ten healthy participants, with mean age of 24.9 ± 5.0 (SD) years, height 168.3 ± 8.8 cm, weight 62.7 ± 12.3 kg, were tested for the SOL H-reflex (H_max) on two separate occasions within 7 days. The intraclass correlation coefficient (ICC) for the test–retest of the SOL H-reflex during rest was found to be high at ankle joint angle of neutral (ICC = 0.92) and plantarflexion (0.96), and moderate at dorsiflexion (0.75). Inconsistent ICC values (range from 0.62 to 0.97) were found during the submaximal voluntary contractions at the three ankle joint positions. High ICCs were also found in H_max/M_max ratio at neutral (0.86), plantarflexion (0.96), and dorsiflexion (0.84) positions. It was concluded that the test–retest reliability of the SOL H-reflex was affected by the intensity of voluntary contraction and ankle joint position. The H-reflex demonstrated a higher reliability at the neutral and plantarflexion positions than that at the dorsiflexion position during rest, and a higher reliability at 10% MVC than that at 30% and 50% MVC.     

Spatial distribution of surface action potentials generated by individual motor units in the human biceps brachii muscle

This study analyses the spatial distribution of individual motor unit potentials (MUPs) over the skin surface and the influence of motor unit depth and recording configuration on this distribution. Multichannel surface (13 × 5 electrode grid) and intramuscular (wire electrodes inserted with needles of lengths 15 and 25 mm) electromyographic (EMG) signals were concurrently recorded with monopolar derivations from the biceps brachii muscle of 10 healthy subjects during 60-s isometric contractions at 20% of the maximum torque. Multichannel monopolar MUPs of the target motor unit were obtained by spike-triggered averaging of the surface EMG. Amplitude and frequency characteristics of monopolar and bipolar MUPs were calculated for locations along the fibers’ direction (longitudinal), and along the direction perpendicular (transverse) to the fibers. In the longitudinal direction, monopolar and bipolar MUPs exhibited marked amplitude changes that extended for 16–32 mm and 16–24 mm over the innervation and tendon zones, respectively. The variation of monopolar and bipolar MUP characteristics was not symmetrical about the innervation zone. Motor unit depth had a considerable influence on the relative longitudinal variation of amplitude for monopolar MUPs, but not for bipolar MUPs. The transverse extension of bipolar MUPs ranged between 24 and 32 mm, whereas that of monopolar MUPs ranged between 72 and 96 mm. The mean power spectral frequency of surface MUPs was highly dependent on the transverse electrode location but not on depth. This study provides a basis for the interpretation of the contribution of individual motor units to the interference surface EMG signal.     

EMG amplitude and frequency parameters of muscular activity: Effect of resistance training based on electromyographic fatigue threshold

The present study aimed to evaluate the effect of a resistance training program based on the electromyographic fatigue threshold (EMG_FT, defined as the highest exercise intensity performed without EMG alterations), on the EMG amplitude (root mean square, RMS) and frequency (median frequency, MF) values for biceps brachii (BB), brachioradialis (BR), triceps brachii (TB) and multifidus (MT). Twenty healthy male subjects, (training group [TG], n = 10; control group [CG], n = 10), firstly performed isometric contractions, and after this, dynamic biceps curl at four different loads to determine the EMG_FT. The TG training program used the BB EMG_FT value (8 weeks, 2 sessions/week, 3 exhaustive bouts/session, 2 min rest between bouts). No significant differences were found for the isometric force after the training. The linear regression slopes of the RMS with time during the biceps curl presented significant decrease after training for the BB, BR and TB muscles. For the MT muscle, the slope and MF intercept values changed with training. The training program based on the EMG_FT influenced EMG the amplitude more than EMG frequency, possibly related to the recruitment patterns of the muscles, although the trunk extensor muscles presented changes in the frequency parameter, showing adaptation to the training program.     

The effects of isometric and isotonic training on hamstring stiffness and anterior cruciate ligament loading mechanisms

Greater hamstring musculotendinous stiffness is associated with lesser ACL loading mechanisms. Stiffness is enhanced via training, but previous investigations evaluated tendon rather than musculotendinous stiffness, and none involved the hamstrings. We evaluated the effects of isometric and isotonic training on hamstring stiffness and ACL loading mechanisms. Thirty-six healthy volunteers were randomly assigned to isometric, isotonic, and control groups. Isometric and isotonic groups completed 6 weeks of training designed to enhance hamstring stiffness. Stiffness, anterior tibial translation, and landing biomechanics were measured prior to and following the interventions. Hamstring stiffness increased significantly with isometric training (15.7%; p = 0.006), but not in the isotonic (13.5%; p = 0.089) or control (0.4%; p = 0.942) groups. ACL loading mechanisms changed in manners consistent with lesser loading, but these changes were not statistically significant. These findings suggest that isometric training may be an important addition to ACL injury prevention programs. The lack of significant changes in ACL loading mechanisms and effects of isotonic training were likely due to the small sample sizes per group and limited intervention duration. Future research using larger sample sizes and longer interventions is necessary to determine the effects of enhancing hamstring stiffness on ACL loading and injury risk.