The “Kneed” For Multi Joint Assessment

Injuries to the knee, both acute and overuse related are common in jump-landing movements, especially in female athletes (Agel et al., 2005; Boling et al., 2010). Amongst these, anterior cruciate ligament (ACL) injuries are seen to carry life-long implications, a point that should be heeded by their high prevalence in young populations (Griffin et al., 2006).  Torn ACLs increase osteoarthritis (OA) risk, regardless of any subsequent ACL reconstructive interventions (Daniel et al., 1994). Furthermore, a recent study (Shanahan et al., 2015) has highlighted changes to the motor cortex in OA subjects compared to controls, a change also accompanied by a negative effect on movement quality. With regards to the Movement Health philosophy, in which movement is seen to be a supplier of choice in how people live their lives, across the whole of their lives, prevention of the initial ACL injury is would appear profoundly important.

Views of the need for prevention are evident within the literature (Hashemi et al., 2011).  The same authors’ excellent 2011 perspective on ACL injury mechanism highlight another point of note ‘As ACL injury occurs when stress on the ligament exceeds its failure strength (Slauterbeck et al., 2006), ACL loading is often treated as a purely single joint (tibio-femoral) phenomenon’

It’s not just about the knee

During the assessment of movement there is the need to consider the whole system as opposed to focussing on the site of potential injury or even just consideration of the lower extremity.   Here are some points from associated literature supporting this stance:

  • Sagittal plane hip kinematics should be considered as a direct contributor to ACL injury risk (Hashemi et al., 2011). – therefore consider the hip
  • Landing with an upright trunk position in the sagittal plane increases vertical ground reaction forces (Shimokochi et al., 2012) which is believed to increase both acute and overuse knee injury risk (Aerts et al., 2013; Mendiguchia et al., 2011).- therefore consider the trunk
  • Landing with the combination of an increased knee flexion moment and a decreased hip flexion moment, is characterized by an overreliance on the quadriceps muscles (Malfait et al., 2014; Shimokochi et al., 2012). This is also considered to be related to reduced contributions from the hip extensors in the attenuation of ground reaction forces (Pollard et al., 2010; Sigward et al., 2011). Less involvement from the gluteus maximus is likely to see an increase in hip adduction (frontal plane) and medial rotation (transverse plane) due this structure’s roles (Neumann, 2010). These patterns are also commonly associated to ACL risk. – therefore, the movement seen in one plane will be informative on others if we also consider the synergistic contributions at that site. Multi-plane- multi joint is necessary. 
  • Participants who use less hip flexion during the deepest position of a depth jump are seen to rely increasingly on frontal plane knee moments to decelerate the body centre of mass (Dingenen et al., 2014). – the movement at one region will often influence the movement at another and this may also raise risk – Multi-plane- multi joint is necessary.
  • Decreased ankle dorsiflexion range of motion has been associated with anterior cruciate ligament injuries (Boden et al., 2009). – therefore, consider the compensations for restrictions as risk factors as the lack of dorsi flexion is likely to be accommodated elsewhere.

Multi Joint assessment

Above and below the site of injury, movements are observable that are strongly implicated in its occurrence. Assessing the body as an integrated unit allows the ensemble of its movement related risk factors to be captured. Yet, there is the need to label what is identified at the specific regions in which deficits in movement quality occur. The site, the direction and threshold of muscle recruitment of this impairment can be chronicled and addressed supplying a route to maintain movement health for the long term.

Find out more

Check out our earlier post Point Break, part of our ongoing theme about stress fractures.

If you would like to put movement into your clinic contact Andy Hosgood The Performance Matrix’s business development consultant

See our Kinetic Control Education page for details on all our learning routes, including the modular system, The Movement Solution masterclasses, our online learning platform and the modules at MSc credit modules at Keele University


  1. Aerts, I., Cumps, E., Verhagen, E., Verschueren, J., & Meeusen, R. (2013). A systematic review of different jump-landing variables in relation to injuries. J. Sports Med Phys Fitness; 53:509–19.
  2. Agel, J., Arendt, E. A., Bershadsky, B. (2005). Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med ;33:524–30.
  3. Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S., Beutler, A. (2010). Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports;20:725–30.
  4. Daniel, D, M., Stone, M, L., Dobson, B, E., et al., (1994). Fate of the ACL-injured patient. a prospective outcome study. Am. J. Sports Med. 22 (5), 632–644.
  5. Griffin, L.Y., Albohm, M.J., & Arendt, et al., (2006). Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting. Am. J. Sports Med. 34, 1512–1532.
  6. Hashemi J., Breighner, R., Chandrashekar, N., Hardy, D. M., Chaudhari, A. M., Shultz, S. J., et al. (2011). Hip extension ,knee flexion paradox: a new mechanism for non-contact ACL injury. J Biomech ;44:577–85.
  7. Shanahan, C. J., Hodges, P. W., Wrigley, T. V., Bennell, K. L., & Farrell, M. J. (2015). Organisation of the motor cortex differs between people with and without knee osteoarthritis. Arthritis Research & Therapy17(1), 164. doi:10.1186/s13075-015-0676-4.
  8. Shimokochi, Y., Ambegaonkar, J. P., Meyer, E. G. , Lee, S. Y. , & Shultz,  S. J. (2012). Changing sagittal plane body position during single-leg landings influences the risk of non-contact anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc; 21:888–97.
  9. Slauterbeck, J.R., Hickox, J.R., Beynnon, B., Hardy, D.M., (2006). Anterior cruciate ligament biology and its relationship to injury forces. Orthop.Clin.NorthAm.37 (4), 585–591.