title: Hamstrings loading contributes to lateral patellofemoral malalignment and elevated cartilage pressures: an in vitro study.
abstract: BACKGROUND
  Hamstrings loading has previously been shown to increase tibiofemoral posterior translation and external rotation, which could contribute to patellofemoral malalignment and elevated patellofemoral pressures. The current study characterizes the influence of forces applied by the hamstrings on patellofemoral kinematics and the pressure applied to patellofemoral cartilage.
  
  
  METHODS
  Ten knees were positioned at 40°, 60° and 80° of flexion in vitro, and loaded with 586 N applied through the quadriceps, with and without an additional 200 N applied through the hamstrings. Patellofemoral kinematics were characterized with magnetic sensors fixed to the patella and the femur, while the pressure applied to lateral and medial patellofemoral cartilage was measured with pressure sensors. A repeated measures ANOVA with three levels, combined with paired t-tests at each flexion angle, determined if loading the hamstrings significantly (P<0.05) influenced the output.
  
  
  RESULTS
  Loading the hamstrings increased the average patellar flexion, lateral tilt and lateral shift by approximately 1°, 0.5° and 0.2mm, respectively. Each increase was significant for at least two flexion angles. Loading the hamstrings increased the percentage of the total contact force applied to lateral cartilage by approximately 5%, which was significant at each flexion angle, and the maximum lateral pressure by approximately 0.3 MPa, which was significant at 40° and 60°.
  
  
  CONCLUSIONS
  The increased lateral shift and tilt of the patella caused by loading the hamstrings can contribute to lateral malalignment and shifts pressure toward the lateral facet of the patella, which could contribute to overloading of lateral cartilage.
authors.affiliation: Department of Orthopaedic Surgery, Akron General Medical Center, OH, USA. john.elias@akrongeneral.org
authors.forename: John J
authors.initials: JJ
authors.lastname: Elias
authors.forename: Marcus S
authors.initials: MS
authors.lastname: Kirkpatrick
authors.forename: Archana
authors.initials: A
authors.lastname: Saranathan
authors.forename: Saandeep
authors.initials: S
authors.lastname: Mani
authors.forename: Laura G
authors.initials: LG
authors.lastname: Smith
authors.forename: Miho J
authors.initials: MJ
authors.lastname: Tanaka
mesh_terms: D000368:Aged; D001696:Biomechanical Phenomena; D002102:Cadaver; D002356:Cartilage / Q000473:pathology*; D005260:Female; D005269:Femur / Q000033:anatomy & histology*; D006801:Humans; D066298:In Vitro Techniques; D007717:Knee / Q000033:anatomy & histology; D007719:Knee Joint / Q000033:anatomy & histology; D008297:Male; D008875:Middle Aged; D008953:Models, Anatomic; D015233:Models, Statistical; D010329:Patella / Q000033:anatomy & histology*; D011312:Pressure; D013314:Stress, Mechanical