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# ARTICLE IN PRESS

## Current Orthopaedics (2006) 20, 23–31

Available at www.sciencedirect.com

## (iv) Basic biomechanics of human joints:

Hips, knees and the spine
T.D. Stewarta,, R.M. Halla,b

a
Institute of Medical and Biological Engineering, c/o School of Mechanical Engineering, The University of Leeds,
Leeds LS2 9JT, UK
b
Academic Unit of Orthopaedic Surgery, School of Medicine, The University of Leeds, Leeds LS2 9JT, UK

KEYWORDS Summary
Biomechanics; The paper provides a basic introduction to the biomechanics of the hip, knee and spine
Hip; with respect to the healthy joint and following joint replacement. The content is aimed
Knee; specifically at persons with a medical background to introduce them to the concepts of
Spine forces and moments in application to the human body.

Basic principles of mechanics (forces and ceramic-on-ceramic artificial hip replacement or variable as
moments) is the case in the functional spinal unit or knee. The
magnitude of the moment is calculated by multiplying the
force by the perpendicular distance from the line of action
Forces and moments (torque) can be described by referring
of the force vector to the reference point. The seesaw
to the child’s seesaw in Fig. 1. Standing stationary a child
example below explains the basic principles. If Child A sits
will exert a force onto the ground which is equal to the
on the left end of the seesaw the bar will rotate downward,
product of the child’s mass and the acceleration due to
in the counterclockwise direction. In engineering terms,
gravity (9.81 m/s2). Therefore, a child of 30 kg in mass would
counterclockwise rotation is termed a positive moment, or
exert a downward force of 294.3 N to the ground (their
positive torque. The magnitude of this torque would be
weight). Note that if the child jumped onto the ground the
equal to the product of the weight of Child A (294.3 N)
acceleration term in the equation (force ¼ mass  accelera-
multiplied by the distance (a) the child is sitting from the
tion) would increase, as would the force.
centre of rotation of the beam (2 m), in this case the
A force acting on a body can produce rotation as well as
magnitude of the moment would be equal to 588.6 Nm
translation. This rotation is caused by a rotational torque,
(294.3 N  2 m). The distance itself is also termed the
also referred to as a moment. A moment is caused when a
moment or lever arm.
force acts at a particular distance from a point of reference.
A moment or torque is defined by a magnitude and a
This point of reference may be a fixed axis of rotation as in a
direction and is, therefore, a vector. If a heavier child (Child
B 60 kg in mass) sits on the other side of the seesaw the
Corresponding author. Tel.: +44 0113 343 2133; beam will then rotate in the clockwise direction. For
fax: .+44 0113 242 4611 equilibrium to occur the sum of the moments acting on
E-mail address: T.D.Stewart@leeds.ac.uk (T.D. Stewart). the bar must be equal to zero. Therefore, for the bar to be

doi:10.1016/j.cuor.2005.12.004
ARTICLE IN PRESS
24 T.D. Stewart, R.M. Hall

balanced the product of the weight of Child A and distance a equal to Fgr  Gr. The moment arm Gr is equal to the length
must be equal to the product of the weight of Child B and of the leg (L) multiplied by the sine of the flexion angle
the distance b. As Child B is twice the weight of Child A this (301); Gr is, therefore, equal to 0.5L. Thus, the ground
means that Child B must slide up the bar until his moment reaction force (Fgr) produces a flexion moment of BW  0.5L.
arm (distance b) is equal to one-half of the moment arm The flexion moment is balanced by the extensor muscles
(distance a) of Child A for the seesaw to function effectively. including the gluteus maximus and the hamstrings which act
The moments would then be said to be equal in magnitude to stabilise the hip at heel-strike producing a counter-
but opposite in direction. To calculate the reaction force at clockwise negative moment. In this example, for simplicity,
the pivot of the seesaw you can add up all of the forces the hamstrings muscle alone has been considered. The
acting in the vertical direction. This reaction force would moment produced by the hamstrings muscle is equal to the
then be equal to the combined weight of the two children. magnitude of the hamstrings muscle force (Fh) multiplied by
the distance from the line of action of the muscle to the hip
centre. Thus, the moment arm will vary from person to
The hip person; however, its value will be approximated in this
example to be equal to 0.15L. Therefore, the moment
The bony structures and ligaments of the natural hip create produced by the hamstrings muscle group would be equal to
essentially a ball-in-socket joint. This structure limits Fh  0.15L. For the hip to be stable the ground reaction
anterior/posterior, and medial/lateral translation as well moment (BW  0.5L) must be approximately equal to the
as subluxation (dislocation); however, it does not generally moment produced by the extensor muscles, in this case only
limit the range of motion of the hip during normal daily the hamstrings. Therefore, the hamstrings muscle force Fh
activities. The allowable range of motion is shown in Table 1 at gross approximation would be equal to 3.3 times BW.
when compared to a selection of daily activities. The vertical reaction force at the hip can be calculated by
The range of motion of the hip is far greater than what is summing the forces acting in the vertical direction from
required for normal activities, such as walking. This means Fig. 2. This includes the ground reaction force Fgr and the
that the surrounding bone and ligaments of the hip joint do vertical component of the hamstrings muscle force vector
not provide any rotational stability to the hip joint during Fh cos(30+y1), where y is the angle between the hamstrings
the walking cycle and, therefore, this stability is provided muscle force vector and the line of action of the femur. In
almost entirely by the action of muscle forces. Principles of this case, y is assumed to be equal to 171. Therefore, for this
simple static mechanics can be used to analyse the loading simple example, the vertical reaction force at the hip is
applied within the body. Figure 2 shows a very simple two-
dimensional (2D) schematic of the leg at the heel-strike
phase of gait. Contact with the ground produces a ground
reaction force equal to the proportion of the person’s mass
transferred to the ground multiplied by the acceleration of
this mass (gravitational acceleration+linear acceleration).
The ground reaction force at heel-strike can be measured Gr
experimentally using a simple force platform and was Hs
reported by Bassey et al.6 to be in the region of their body
weight (BW). As the knee is fully extended at heel-strike the
leg can be analysed in a similar manner to the seesaw as
shown in Fig. 2 with the hip joint acting as the pivot. The Fh Hamstrings
ground reaction force acting at the foot (Fgr) produces a Muscle Force
counterclockwise (positive) moment about the hip centre

Child A Child B

Fgr Ground
a b Reaction Force

## Flexion/extension 140/30 30/15 129 40

Internal/external rotation 90/90 4/9 18 abd.
ARTICLE IN PRESS
Basic biomechanics of human joints: Hips, knees and the spine 25

3.00

2.50

Stance Swing
2.00

1.50

1.00

0.50

0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

Time (s)

Figure 3 Vertical reaction force at the hip used for simulation of gait in wear simulators.

Body
Weight AB1

AB2
BW

Offset

## equal to BW+3.3BW  0.68 for a total of 3.25BW. This 2D Hip replacement

calculation is very crude; however, it demonstrates the
general methods which can be utilised to analyse forces and As the wear of replacement joints has improved over the
moments in the body. It also demonstrates the inefficiency past 20 years, correct positioning of the components during
of our muscle forces due to the nature of our relatively long hip replacement is arguably the most important factor for
slender limbs and the resulting short muscular moment the success of modern total hip prostheses. To restore
arms. normal function in the hip joint, an important biomechani-
The vertical hip joint reaction force during walking is cal consideration in total hip replacement is the femoral
shown in Fig. 3. The walking cycle is characterised by two offset. Normal function is in itself an arguable quantity as
peaks of load at heel-strike and at toe-off which generally what one patient would consider normal may limit the
range from 3–4 times our body weight7. Between these two activities of another.
loading peaks the body’s mass (head and torso) is moving The femoral offset is the distance from the centre of
smoothly and is not translated vertically a large amount. rotation of the hip joint to the line of action of the femur, as
As such the reaction force at the hip between heel-strike outlined in Fig. 4.8 To understand the importance of offset
and toe-off is relatively small and in the region of body consider the example shown below of a person standing on
weight. At toe-off the hip is extended 15 degrees. The one leg whilst their body remains vertical. The BW of the
quadriceps muscle acts to stabilise the knee whilst the person will create a clockwise (negative) moment or torque
gastrocnemius muscle produces plantarflexion at the ankle. about the centre of the hip. This torque must be balanced by
These muscle forces combine to accelerate the body an equal but opposite counterclockwise (positive) moment
forward producing the second peak of load in the reaction produced by the abductor muscle force. The moment arm of
force curve. the abductor muscle is directly related to the magnitude of
ARTICLE IN PRESS
26 T.D. Stewart, R.M. Hall

the femoral offset. As the offset increases in length the in geometry allows a wide range of motion to occur which
force required by the abductor muscles to balance the BW allows us to complete various daily activities. The allowable
moment would reduce, thereby increasing the efficiency of range of motion in the knee is shown in Table 2 when
the abductors. The reaction force at the hip would also compared to a selection of daily activities.
decrease in this case since the sum of the forces acting in The corresponding reaction forces at the knee during
the vertical direction would reduce with the smaller walking are shown in Fig. 5. The reaction forces must be
abductor muscle force. Increasing the femoral offset may considered in parallel to the flexion–extension of the knee
result in increased stress transferred to the femoral (Fig. 6) in order to fully understand their significance
component and its fixation due to the larger bending towards the characteristic three peaks of load which occur
moment produced by a longer neck length, however, as this during walking.
is combined with a reduced joint load the overall effect on At heel-strike contact with the ground produces a flexion
the stress distribution would be more complex with greater moment at the hip, and an extension moment at the knee,
bending stress, but, reduced normal stress, a topic which is both of which are resisted by the hamstrings muscle. At this
beyond the scope of this paper. position, the knee is fully extended and there is a loading
peak across the joint upon impact of 2–4 times BW,
primarily due to muscle forces acting to stabilise the knee.9,12
The knee When our heel hits the ground the knee is in its most
stable position due to three factors.1,10 The medial/lateral
The knee joint consists of two articulating joints the tibio- spacing of the femoral condyles is the least when the knee is
femoral joint and the patello-femoral joint. Unlike the ball- fully extended. At this position, the condyles tighten against
in-socket geometry of the hip the femoral and tibial surfaces the intercondylar notch (tibial spine) thereby providing bony
of the knee are not a close fit to one another. The variation stability. The radius of curvature of the femoral condyles is

## Flexion/extension 150/51 70/0 100–1201 70–901

Internal/external rotation 76/7301 7101
Rollback (M/L) 5/15 mm 8

3.00

2.50

2.00

1.50

1.00
Swing
Stance

0.50

0.00
0 20 40 60 80 100

## Percentage of Gait Cycle

Figure 5 Vertical tibio-femoral knee reaction force used for simulation of gait in wear simulators.
ARTICLE IN PRESS
Basic biomechanics of human joints: Hips, knees and the spine 27

60

50

40

## Posterior Displacement (mm)

Internal Rotation (degrees)
Flexion Angle (degrees)

30
Swing
Stance

20

10

0 20 40 60 80 100
-10

## Percentage of Gait Cycle

-20
Figure 6 Motion of the knee used for simulation of gait in wear simulators.

largest when the knee is fully extended. The tibial plateau is translation of the femur relative to the tibia that occurs
also sloped anteriorly and the combination of these two during the rolling action is restricted by the anterior
factors pull the collateral ligaments taught at extension. The cruciate ligament which acts like an anchor preventing
result of the bony structures and taught ligaments creates a posterior translation. As flexion continues and the condyles
structure that is rotationally very stable at heel-strike. can no longer roll backward on the tibia the motion between
An additional factor to consider at heel-strike is the the femoral and tibial surfaces changes from rolling to
translational stability of the knee. When the foot contacts the sliding. This change occurs initially with the medial condyle
ground a natural anterior translation of the femur with and then the lateral condyle resulting in a natural external
respect to the tibia occurs. Anterior translation of the femur rotation of the knee. At toe-off (501 flexion) the
is restricted by the posterior cruciate ligament which quadriceps calf muscle (gastrocnemius) act to both stabilise
prevents forward dislocation of the bearing. Unlike the hip, the knee joint and produce plantar flexion of the ankle joint
stability in the knee at heel-strike is, therefore, provided by a which accelerates the body forward resulting in a vertical
combination of bony structures, ligaments and muscle forces. joint reaction force of 2–4 times BW.9 A recent paper by
As walking progresses into mid-stance the knee begins to Freeman and Pinskerova12 is recommended for further
flex due to actions of the hamstrings muscles and the reading.
femoral condyles begin to roll on the tibial surface. This
produces a natural posterior translation of the contact with
Knee replacement
the tibia along with an external rotation (51) of the knee
since the lateral femoral condyle has a larger radius and
rolls further. The knee flexes to 201 (hamstrings) and then Much like the hip correct positioning of the components
extends (quadriceps) back to 01.1,10 At the change in during knee replacement is also vital in its success. The
direction from flexion to extension a second loading peak general alignment issues of the hip all hold true for the knee
occurs in the knee as the muscle forces act to stabilise the with even greater importance since the knee has a less
joint. During mid-stance the knee is less stable since the conforming geometry and high stresses can lead to
accelerated wear and delamination.13 Among the important
medial/lateral spacing of the femoral condyles is larger and
they no longer lock against the intercondylar notch. In factors for knee replacement positioning include rollback,
addition to this, the radius of curvature of the femoral tibial position/size, varus/valgus positioning and lift-off.
condyles during flexion is decreasing, and the natural
rollback in the knee is pushing the contact down the Rollback
posterior sloping tibial plateau which brings the femur closer The posterior shift in the contact between the femur and
to the tibia and increases the laxity in the ligaments. This the tibia during flexion (rollback) increases the moment arm
laxity allows relative rotation between the femoral and and efficiency of the quadriceps muscle.14 This is outlined in
tibial surfaces to occur. the schematic of Fig. 7. As flexion occurs, such as during a
As walking continues the knee flexes once again. Rolling squat, the efficiency of the quadriceps muscle force will be
occurs up to 201 flexion until at which time the posterior directly related to tension and moment arm (PT) of the
ARTICLE IN PRESS
28 T.D. Stewart, R.M. Hall

patella tendon. Clearly, without rollback the moment arm is patellar arthrotomy was conducted. This left very poor
short and a larger force is required by the muscle to produce quality cancellous bone to support the medial side which
the same action. subsided. Complete coverage is difficult due to the
While rollback occurs naturally in the healthy knee, anatomical nature of the tibial plateau which extends
replacement joints are sometimes designed with a cam further posteriorly on the medial side.
arrangement to encourage natural motion. Knee biomechanics Overhang of the tibial insert is equally as important as
following total knee replacement has been shown to be highly undersizing. In some areas an overhanging tray can lead to
variable in clinical studies, with great patient variability.14–17 impingement with the ligaments and tendons surrounding
the knee and cause discomfort, pain and the need for
revision.
Tibial positioning/size
Incomplete support by the tibial cortex (cortical bone) for
Varus/valgus positioning and lift-off
the tibial tray may lead to subsidence of the tibial tray if In the natural knee, it is generally considered that 60% of
cancellous bone quality is poor.18 Generally, anterior medial
the load is transferred through the medial condyle while 40%
and posterior lateral coverage is recommended when sizing
is transferred through the lateral condyle. In a knee with
components to prevent subsidence. An example of sub- valgus deformity, the biomechanics and of the knee have
sidence is shown in Fig. 8. The tibial insert in this case was
changed significantly so that the majority of the load is
lateralised as the patient had a valgus deformity and a para-
transferred through the medial condyle. In contrast in a
knee with a varus deformity, the majority of the load is
Quadriceps transferred through the lateral condyle. Following knee
polyethylene tibial insert caused by a varus/valgus defor-
Femur Femur mity or by condylar lift-off has been shown in in vitro studies
to cause accelerated wear of the polyethylene and should,
“PT” “PT”
therefore, be avoided.19,20

## There are two common methods for measuring the load

Reaction Force Reaction Force
acting on our joints. Inverse dynamics uses simple engineer-
ing mechanics as illustrated in Fig. 2 in the application of the
Patella Tendon
body. The second method of measuring joint forces is to
Figure 7 Schematic of the effect of rollback on the quadriceps utilise instrumented prostheses.22 These are custom de-
moment arm (PT). signed implants which contain complex instrumentation that

Anterior
0
340 350 10 20
330 40 30
320 40
310 30 50
300 60
20
290 70
280 10 80
270 0 90
Lateral Medial
260 100
250 110
240 120
230 130
220 140
210 150
200 190 170 160
180
Posterior
L3-91 L3-92 L3-93 L3-94 L3-95 L3-96
L3-97 L3-98 L3-99 L3-100 Average Cad file 3

Figure 8 Medial tibial collapse (left) of a lateralised tibial component. Typical coverage of a tibial tray (dark line) and average
patient data (right).
ARTICLE IN PRESS
Basic biomechanics of human joints: Hips, knees and the spine 29

12
Walking Freeman and Pinskerova 3.4 BW
Paul7 3–4 BW 3 BW
Bergmann et al.22 (in vivo normal) 2–3 BW
Bergmann et al.22 (in vivo defective) 3–4 BW

## Stair ascent/descent Freeman and Pinskerova12 4.8/4.3 BW

Costigan et al.23 3–6 BW
Paul7 4.4/4.9 BW
Bergmann et al.22 (in vivo normal) 2–3.5 BW
Bergmann et al.22 (in vivo defective) 3.5–5 BW

## Rising from a chair Ellis et al.11 3.2 BW

Bergmann et al.22 (in vivo normal) 1.75–2.25 BW

Paul7 4.2 BW

## directly records the load acting on the joints in-vivo. Ethical

Table 4 Key biomechanical functions of the spine.24
approval is required for the use of these devices. Typical
loads measured within the body during various activities for 1 Protection of the spinal cord
the hip and knee are shown in Table 3. 2 Maintenance of trunk stability
Kinesiology (inverse dynamics) has a tendency to over- 3 To provide mobility
estimate joint forces due to assumptions related to the 4 Aid movement in the upper and lower limbs
actions of muscles. In contrast, instrumented prostheses
may produce more accurate results; however, there is a vast
difference in the biomechanics from patient to patient.
Therefore, to achieve an average value for a given This is because of the high loads that must be sustained, and
population the sample must be very large to overcome the the complex neuromuscular control that is required to
variability. The results from inverse dynamics and from maintain a stable yet mobile unit. The limits of the
instrumented prostheses are reasonably close and as long as compressive loads within the spine are defined, principally,
you understand the limitations used in the analysis—either by the axial strength of the individual vertebrae (Fig. 9) that
method is a very useful and valuable tool. rise from approximately 1300 N at C3 (the third cervical
vertebra) to over 8000 N at L4 (the fourth lumbar verte-
bra).25 Whilst a considerable margin of safety is built into
The spine
these failure strengths the loads observed in the spine are
often several times BW. The only time the compressive load
The spine, comprising three joints at any level—a disc and
is less than BW is in mainly the prone position.
two facet joints, is arguably the most complex and
The compressive forces arise largely from the muscle
demanding of any joint systems within the human body.
action that produces a counterbalancing moment to the
Harms and Tabasso24 noted the importance of restoring the
weight of the upper torso and/or head that acts forward of
normal biomechanical environment as far as is possible
the spine (Fig. 10) in a manner similar to the example given in
during a surgical intervention and have proposed four key
Fig. 1. The posterior muscles have a relatively small moment
biomechanical functions for the spine (Table 4).
or lever arm (b is typically 5 cm or less) and, therefore, have
The key feature of this list is that the functions are listed
to produce a considerably larger force than the weight of the
in ascending order of importance and with the clinician give
upper torso to produce a counterbalancing moment. The
a set of principles by which an intervention should be
compressive load on the spine at that level is just the
approached. For example, the overriding concern is protec-
addition of the weight of the upper torso and the force
tion of the spinal cord which takes precedence over other
generated by the posterior muscles. The axes of rotation of a
considerations. If the functioning of the spinal cord can be
given functional spinal unit, which is the disc and the
assured then the stability of the spine should be the next
adjacent two vertebrae, are generally located in or just
important consideration as is the case in fusion surgery. This
below the disc, but the exact position will vary according to
is achieved at the expense of the segment’s mobility.
the type of motion being undertaken, the position of the
spine and the nature of the individual as well as the
Loads in the spine functional spinal unit being observed. This simple figure can
be amended to include a person carrying a weight in front of
As previously noted the spine, particularly the lumbar them. In this case, the posterior muscles will have to
segment, experiences arguably the most demanding biome- counterbalance an additional torque and therefore produce
chanical environment of any joint system in the human body. an even greater force to resist the forward flexing moment.
ARTICLE IN PRESS
30 T.D. Stewart, R.M. Hall

9000 350
300

Force (% Bodyweight)
8000 250
200
150
7000
100
Compressive strength (N)

50
6000
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95100
5000 Stride (%)

20
4000

Anterior
15

Force (% Bodyweight)
10
3000
5

2000 0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95100
-5

Posterior
1000 -10
-15
0 Stride (%)
C3 T1 T5 T11 L1 L4
15
Figure 9 Strengths of vertebral bodies in different spinal 10

Left
Force (% Bodyweight)
regions.
5

0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95100
-5

Right
Weight of the Action of the -10
Upper Torso Muscles
-15
Posterior to Stride (%)
the Spine
a Figure 11 Typical loads observed in L4–L5 functional spinal
unit. The uppermost diagram outlines the axial compressive
Figure 10 A counterbalancing moment produced by the the lateral shear.26 Note the double peaks in both the
muscles posterior to the spine acts to prevent the body flexing compressive and antero-posterior shear loads that follow heel-
forward in response to the weight of the upper body. strike of both the left and right foot during one gait cycle.

During level walking, the peak compressive forces Motions in the spine
developed across L4–L5 fluctuate between 1.5 and 3 times
BW,26 and they do so at a frequency twice that of the gait Spinal motion is difficult to measure due to the segmented
cycle (Fig. 11). Impressively high transient loads (5–6 times nature of the spine and the exceedingly high number of
BW or greater27–34) occur for more extreme forms of activity degrees of freedom together with elevated degree of
or at the extremes of motion, with trunk flexion and/or high redundancy that this allows. This must be coupled with
external loading being especially demanding. However, issues of accessibility that may preclude routine non-clinical
substantial loads are sustained even during ‘inactively’ radiographic imaging of the spine with which to observe the
standing or sitting (1.5 and 2.0 times BW, respectively35). behaviour of individual functional spinal units. Segmental
Also of importance are the observations of the shear forces motion assessment is more common in which surface
in the lower lumbar spine. These loads are a source of much measurement type devices are used. However, these have
debate, in particular, on whether total disc replacements a number of shortcomings in that they are prone to the usual
(TDRs) should be constrained or not, together with the uncertainties found to be common with the use of surface
effects these design features have on the adjacent markers but also the fact that the translational motion is
structures, in particular, the facet joints. The important often excluded from the analysis, which suggests that such
antero-posterior shear loads, which have been inferred from motion is unimportant within the spine.
indirect measurement, can exceed 140 N during normal Observations show that the overall range of motion in
walking to more than 1000 N in more extreme activ- flexion/extension varies enormously throughout the spine
ities.26,27,32–34 When considering any surgical intervention and varies within anatomical segments as well as between
the clinician must also ensure that the forces and moments them. Combined flexion–extension is relatively high in both
are distributed physiologically between the different struc- the cervical and lumbar regions exceeding 101 whilst a
tures within the spine with special reference to the facet minimum is observed in the upper and mid-thoracic regions.
joints. Typically, in the neutral position, 80% of the The range of motion for lateral flexion is more even
compressive load passes through the vertebral bodies and throughout the spine with values typically between 51 and
20% through the facets in the lumbar spine, whilst in the 101. The lower thoracic and lumbar spines are characterised
cervical spine a greater proportion passes through the by a relatively small range of motion in axial rotation which
anterior column. is typically of the order of 31, which results from the
ARTICLE IN PRESS
Basic biomechanics of human joints: Hips, knees and the spine 31

orientation of the facets which hinder this type of motion.25 18. Castle TH, Noyes FR, Grood ES. Posterior tibial subluxation of
During gait, the peak-to-peak flexion/extension motion in the posterior-cruciate deficient knee. Clin Orthop Relat Res
the lumbar spine increases with strenuousness of cadence, 1990:193–202.
although the range utilised (typically 3–41) remains only a 19. Jennings LM, Bell CB, Ingham E, Komistek R, Stome MH, Fisher
modest fraction of that fully available. As noted previously, J. The influence of femoral condylar lift-off on the wear of fixed
further complexity arises from the fact that the motions of bearing artificial knee joints. Proc Eur Soc Biomater 2004.
20. Insall JN, Scuderi GR, Komistek RD, Math K, Dennis DA,
the lower lumbar spine are kinematically coupled: most
Anderson DT. Correlation between condylar lift-off and
significantly, flexion/extension results in translational mo- femoral component alignment. Clin Orthop Relat Res 2002;403:
tion, thus causing the instantaneous axis of rotation to 143–52.
migrate. These coupled translations are of the order of 21. Dahlkvist NJ, Mayo P, Seedhom BB. Forces during squatting and
1–2 mm for L4–L5 and 0.5–1 mm for L5–S1,36,37 but they are rising from a deep squat. J Eng Med 1982;11:69–76.
highly variable due to the differences in functional spinal 22. Bergmann G, Deuretzbacher G, Heller MO, Graichen F,
unit recruitment patterns occurring in forward versus Rohlmann A, Strauss J, et al. Hip contact forces and gait
backward trunk bending between individuals.26,38–40 patterns from routine activities. J Biomech 2001;34:859–71.
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