Si 1

Isokinetic Evaluation of Muscular Performance:

Implications for Muscle Testing and Rehabilitation

I? Kannus
The UKK Institute for Health Promotion Research and Tampere Research Station of Sports Medicine, Tampere, Finland

Abstract Many internal and external factors in the

isokinetic testing procedure can have an undesirable effect on
P Kannus, Isokinetic Evaluation of Muscular the test result. However, through proper education and strict
Performance: Implications for Muscle Testing and Rehabilita- adherence to the test instructions, it is possible to successfully
tion. mt j Sports Med. Vol 15, Suppi 1, pp S11—S18, 1994. control the confounding variables.

Interfacing of microprocessors with In scientific work, isokinetic devices have

isokinetic dynamometers has enabled the rapid quantification greatly expanded the possibilities for studying dynamic
of many parameters of muscle function including peak torque, muscle function. There is also little doubt about their useful-
angle-specific torque, work, power, torque acceleration ness in documenting the progress of muscular rehabilitation.

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energy, and various endurance indexes, and the measurements
with these devices can be made isometrically at various angu- A disadvantage of isokinetic devices is that
lar positions and isokinetically (concentrically or eccentri- isokinetic movement seldom occurs in actual human perform-
cally) with a large scale of angular speeds. ance tasks and that the isokinetic training effect is, therefore,
quite (although not completely) specific to that type of move-
Many of these parameters, however, lack evi- ment. In addition, being normally an isolated joint exercise,
dence of validity, reproducibility, and/or clinical relevance. isokinetic training can produce large loads on the involved
Peak torque has been and still is the most properly studied joints and may, therefore, under certain conditions be danger-
isokinetic strength testing parameter and its use can be recom- ous for healing tissues.
mended for research and clinical purposes. Concerning testing
of muscular endurance, the absolute endurance parameters Key words
(for example, work performed during the last five repetitions
and total work in a 25-repetition test with a speed of 240 C/s) Isokinetic contraction, muscle performance,
are the best for use. rehabilitation, testing

Introduction _________
urements that can be used with these machines (Fig. 1). In
isometric contraction, a muscle pulls against an immovable re-
The development of isokinetic dynamometers sistance and thus the muscle-tendon unit does not change in
has instigated considerable research on the in vivo charac- length. Concentric contraction, which can be isotonic (fixed
teristics of human muscles (43,59). At the same time, isokinetic load. changing angular velocity) or isokinetic (fixed angular
machines have created lots of clinical applications for injury velocity, changing load) by nature, involves shortening of the
rehabilitation. In addition to the measurements of muscular
torque, work, or power, commercially available isokinetic dev-
ices have offered a possibility to measure muscular "explo-
siveness" (the rate of torque production) and endurance as well
(8,43,45), which may partly explain their popularity. Many of
these offered parameters have suffered. however, from poor
scientific evidence concerning their validity, reproducibility,
and/or clinical importance decreasing their applicability for
routine use, respectively (8,42,43,47,54,62,67).
The types of muscle contraction and nature of
the applied external load (constant or changing resistance
throughout the range of motion) determine the types of meas- ISOMETRIC CONCENTRIC ECCENTRIC

lot. J. Sports Med. 15(1994) Sll—518

Fig. 1 The isometric, and concentric and eccentric isotonic (con-
stant load) types of muscle contraction.
Georg Thieme Verlag Stuttgart New York
S12 1. J Sports Med. 15 (1994) 1? Kannus

muscle-tendon unit. In eccentric contraction, isotonic or decline with increasing velocity (the torque-velocity relation-
isokinetic by nature, the force that is developed by a muscle in ship) (Fig. 3). The reason for such a decline is in the different
question is overcome by an opposing force of the load so that recruitment capability of different muscle fibers (20). At lower
the muscle merely provides active resistance as the opposing speeds, both type I and II fibers can be maximally activated
force stretches it to a more lengthened position (67). while with increasing angular velocity minor and minor fiber
population will be recruited so that the slow-twitch type I fibers
Being completely computer controlled, the will remain passive first followed by the fast-twitch type hA
newest and most expensive isokinetic dynamometers allow the fibers. The type JIB fibers will be the last to be able to be
research to measure muscle performance isometrically at recruited, but finally, usually with very high angular velocities,
various angular positions and isokinetically (either concen- the torque output becomes zero.
trically or eccentrically) with a large scale of angular speeds.
Theoretically, even during one performance (for example, knee Isokinetic devices usually routinely report the
extension from 90 degrees to full extension) the speed of the joint angle (degrees) at which the PT was achieved (Fig. 2).
lever arm and type of resistance can be changed. Clinical rele- With increasing testing velocity, the PT occurs later in the range
vance of such fine technical possibilities is, however, unclear. of movement (39,59,73; Kannus and Beynnon 1992, unpub-
lished observations). In high angular velocities this may be-
The purpose of this article is to critically re- come a problem since the limb may pass the optimal joint
view the test parameters that isokinetic dynamometers offer and position for muscular performance, and the recorded peak
the factors that may affect the test results, and give recom- torque may not represent the subject's maximal torque capacity
mendations for muscle testing and rehabilitation. (4,59). For this reason, comparisons of peak torque across
velocities irrespective of joint position may yield erroneous
Isokinetic Test Parameters conclusions regarding the state of muscle function (59). Also it
Peak torque should be kept in mind that in weak muscle groups, such as
female hamstrings, the PT angles are affected by muscle

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The most frequently used isokinetic measure- strength so that the weaker the muscle the later the PT occurs
ment in clinical and scientific work has been peak torque (PT, (39; Kannus and Beynnon 1992, unpublished observations).
unit: newton meters, Nm), referring to the single highest torque Most likely this is due to slow neural recruitment of the muscle
output of the joint produced by muscular contraction as the limb in question.
moves through the range of motion (Fig. 2) (9, 26, 34,43,63,65).
PT has been shown to be an accurate and highly reproducible
variable to measure (6,8,24,43,48,53,54,62,63,67,72), and its
Ang1e-specflc torque
use in isokinetic tests has been accepted in critical reviews (4, Interfacing of microprocessors with isokinetic
66,67). PT has become a gold standard and reference point in dynamometers has enabled the rapid quantification of many
all isokinetic measurements against which accuracy, precision, other, more specific muscle function parameters than PT. Pre-
and clinical relevance of all other parameters should be com- determined angle-specific torques (ASTs, unit: newton meters,
pared. Nm) are good examples (Fig. 2). The Cybex testing system, for
example, allows the researcher to measure torque at one or two
PT stays almost unchanged between the angu- additional knee angles other than PT angle for each test session.
lar velocities of 0 and 60 /s but shows thereafter almost a linear

Torque (Nm)
Torque
(Nm) 250 • Quadriceps
Hamstrings
200 __________________________

Work
150

100

50

o io 20 30 50 60 70 80 90 Displacement o
(deg) 0 30 60 90 120 50 180 210 240 270 300
PTA = 37 Angular velocity (deg/s)
Fig. 2 A characteristic isokinetic torque-displacement curve of Fig. 3 The peak torque change in knee extension and flexion
male hamstrings. The speed of the dynamometer is 907s. O re- with the increased angular velocity of the isokinetic dynamometer.
fers to a fully extended knee joint. PT = peak torque; PTA peak
torque angle; AST = angle-specific torque; TAE torque accelera-
tion energy.
Iso/cinetic Evaluation of Muscular Performance mt. .1 Sports Med. 15 (1994) S13

The reliability of the AST measurements has sprinters) may be an exception if the whole power-velocity
been shown to be good when the torque is measured from curve with a wide range of test speeds is determined.
relatively central locations (usually the locations where peak
torque occurs) in the range of motion (7). If, however, the ASTs Peak torque acceleration energy
are measured from more interesting locations (that is, from
more peripheral locations outside the range where the PT usu- Peak torque acceleration energy (PTAE, unit
ally occurs), where ASTs would give real additional informa- joules, J) is defined as the greatest amount of work performed
tion about torque characteristics of an individual, their scientific in the first 125 ms of a single torque production in the test
value and thus clinical usefulness decrease drastically (41,42, repetitions (Fig. 2) (12,43,63). It has been said to be indicative
47). The reason for inconsistent torque results at peripheral of musclar "explosiveness" giving an estimate about the speed
checkpoints may be that many people, especially injured (rate) of the torque production (12).
patients and athletically inactive persons, seldom are able to
control their muscle activity throughout the whole range of Basically, this measurement might be of great
motion. interest among athletes of such sports events as the long jump,
pole volt or ski-jumping, in which the time for maximal torque
For the above-mentioned reasons and for the production is strictly limited and the speed (rate) of the force
fact that the ASTs can be reliably predicted from PT measure- production (not the maximal force as such) is the key factor in
ments (41,42,47), we have concluded that AST analyses offer performance (22). However, the author's recent study showed
little additional information about muscle function to that ob- that isokinetic PTAE measurements, especially during slow
tained from PT and that they (especially those at peripheral speeds of the dynamometers, are too variable and inconsistent
checkpoints) should not be used routinely. to justify their routine use (43). In addition, some researchers
have criticized the concept of "torque acceleration energy" as
Total and peak work lacking a basis from Newtonian physics (64,66).

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Muscular work is best defined and measured as Endurance indexes
output of mechanical energy; that is, externally applied force
multiplied by the distance through which it is applied (67). In Muscular endurance is not an inherent physical
isokinetics, work is defined as the area under the torque versus quantity, but rather a quality of muscle that is semantically the
angular displacement (time) curve (work = torque x distance) opposite of fatigue (67). Baltzopoulos and Brodie (4) defined
(Fig.2) (12,26,43,52,63). Total work (TW, unit =joules, J) is muscular endurance as the ability of the contracting muscles to
the sum of the work performed in the all test repetitions, and perform repeated contractions against load. According to the
peak work (PW, unit =joules, J) is the work done during the Cybex testing manual (12), endurance indicates the rate at
best test repetition, respectively. which a person fatigues during muscular work.

TW and PW seem to be as consistent measure- Various methods of quantifying muscle en-

ments as PT and can be thus used in clinical practice. On the durance have been used, and today there is no universally ac-
other hand, they can be excellently predicted from the PT, and cepted or standardized testing protocol and definition for the
therefore, their clinical usefulness in routine strength tests is assessment of muscular endurance (4). Isokinetic endurance
questionable (29,30,43,55,63,67). Sapega (67) states that in tests typically measure either the number of repetitions of
tests in which the single best score or effort of several attempts maximum effort test movements that are necessary to reach a
is the measure of performance, measurements of work (or 50 % reduction in torque output, or the percent decline in work,
power) may be superfluous. torque, or power from the beginning to the end of a certain time
period or after a certain number of contractions (4,5,8,11,14,
23,45,54,61,67, 74). Absolute parameters, such as work during
Average and peak power
the last five repetitions or total work during all repetitions, have
Muscular power refers to the rate of muscular also been used (8,45,54).
work output and should be expressed in units of work per unit
of time (66). In contrast with torque, power production in The endurance test used by Thorstensson and
isokinetic exercise rises as angular velocity increases (59). This Karlsson (74) consisted of 50 maximal voluntary contractions
means that the magnitude of the torque drop is not sufficient to of knee extension. These authors defined muscle endurance as
offset the effect of speed increase (decrease in movement time) a fatigue index by expressing the mean torque from the last
in continuing to produce a rise in power as angular velocity three contractions as a percentage of the mean torque from the
increases. initial three contractions. Patton et al. (61) expressed the fatigue
index as the time required for muscular exhaustion. BaIt-
Average power (A unit: watts = W = J/s) is zopoulos et a!. (3) defined fatigue index as the decline in
defined as the total work of the given contractions divided by maximum torque over time, using 30 s of repeated reciprocal
the actual total movement time, and peak power (PP unit watts, contractions with gravity-corrected data (speed of the dy-
W) as the amount of work achieved during the best test repeti- namometers was 240 C/s). In Montgomery et al. (54) this time
tion divided by the movement time, respectively (34—36,43,62, was 45 s. Burdett and Van Swearingen (8) measured the number
63). As is the case with TW and PW, AP and PP are consistent of contractions until peak torque fell below 50% of the initial
measurements but well predictable from the corresponding PT peak torque.
values, and therefore, their clinical value may be limited. Test-
ing of top-level power athletes (power and weight lifters, and
S14 mt. .1 Sports Med. 15 (1994) P Kannus

We studied the normality and variability of the inclination, the position of the bench, the use of additional
isokinetic data outputs of absolute (work performed during the supports, and the length of the lever arm) should be available.
last five repetitions and total work in a 25-repetition test with a
speed of 240 / s) and relative (work during the last five repeti- Many other factors can also affect the test re-
tions divided by work during the first five repetitions) en- sult. Sapega (67) lists that data on quantitative testing of muscu-
durance parameters in ten healthy men and ten healthy women lar performance can be affected by variations in velocity of test
(45). Both the hamstring and quadriceps muscles were studied. movements, gravitational forces (Fig. 4), inertial forces (accel-
In addition, half of the subjects underwent a 7-week isokinetic eration, deceleration) during dynamic test movements (impact
training period after which the endurance test was repeated. artefact or torque overshoot, Fig. 5), calibration of the dy-
namometer, damping of the signal from the transducer, adjust-
The results showed that the consistency of the ments of the input lever arm, special dynamometer accessories
above-mentioned absolute parameters was equal to that of the to minimize joint shear, time of the day, and even subject-in-
reference parameter, the peak torque. In addition, the changes duced or ambient noise. Many others, such as limb dominance
after 7 weeks training were very similar; values for all these and testing order, level of verbal encouragement, and personal
parameters increased significantly. Furthermore, since their re- motivation, can be added.
producibility has been shown to be high (8,54), we concluded
that the use of these absolute endurance parameters can be Altogether, it is the experience of the author
recommended for scientific and clinical use. They are also valu- that in order to get reliable results, the most important thing is
able in documenting the progress of endurance training. that the researcher (the person who is leading the test situation)
is well educated and well aware of all these factors which may
The above-mentioned relative endurance para- interfere with the test and data acquisition procedure. Many
meter did not change due to training since both the numerator scientific research projects have shown that if special attention
(work during the last five repetitions) and the denominator is paid to these issues, reliable results can be obtained.
(work during the first five repetitions) improved approximately

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the same amount, keeping their ratio unchanged. Therefore,
along with the fact that the test-retest reproducibility of the
endurance indexes is inferior to that of the absolute parameters
(8,54,62), the author recommends that the isokinetic endurance
indexes should not be used routinely in the clinical setting.

Factors Affecting the Test Results

Before any test, it is very important that the

subject has enough time to familiarize himself/herself with the
system and a possibility to "play" with the machine with
various angular velocities. If not, he / she will do that during the
test which, in turn, will result in underestimation of the true
performance. In other words, he or she will still be in the steeply
ascending part of the learning curve during the actual testing
situation.

Stabilization and positioning of the body are Fig. 4 The gravitational effect on torque
also critical factors affecting both the reliability and validity of (GET) in position B is greater than that in posi-
tests of muscular performance. Manufacturer's instructions tion A since db is greater than da while the
should be strictly followed. Inadequate stabilization of the trunk gravitational force F9 remains the same
or proximal segment of the body, or both, may limit the forces throughout the range of movement. Therefore,
that adjacent muscles can apply to move more distal segments, when the isokinetic dynamometer is used to
record vertical movement torques (e.g., knee
and thus the true performance is underestimated (25). At times, extensions and flexions), all the data pre-
the opposite can occur (67). For repeated measurements, all the sented must be GET corrected. (Adapted
technical data concerning the positioning of the subject (for with permission from Baltzopoulos V., Brodie,
example, dynamometer's height, anteroposterior position and D. A.: Sports Med 8: 101—116,1989.)

300
Fig. 5 Occasionally occurring impact
artefact (IA) or torque overshoot spike in
the torque output represents the "reac-
tion" of the dynamometer to the over-
speeding limb lever arm. IA spike appears
150 in the initial part of the movement and It
E should be eliminated from the final data
z output. (Adapted with permission from
C. Baltzopoulos V., Brodie, D. A.: Sports Med
0 8: 101—116, 1989.)
Isokinetic Evaluation of Muscular Performance mt. .1 Sports Med. 15 (1994) S15

Practival Implications hamstring to quadriceps strength ratio (HQ ratio) is more im-
Data interpretation portant than the maximal torque in the assessment of muscle
function (10).
In interpretation of data collected from such
cross-sectional measurements in which side-to-side compari- In isokinetic machines, the HQ ratios are usu-
Sons are not possible (spine measurements, bilateral joint in- ally automatically calculated and reported. The first research
volvements), a comparative point of reference or standard is reports, which did not correct the gravitational effect on torque,
needed to separate normal from abnormal (1). This may become claimed that the HQ ratio increased with increasing angular
a problem since normative data collected in various studies are velocity (13, 16,69,77). Later studies showed, however, that
always dynamometer-specific and thus not directly applicable such a relationship did not exist if this gravitational effect was
to other testing systems, due to many differences in instrumen- taken into account (2,4,68).
tations, testing protocols, data reduction, and output (15,45,76).
Furthermore, if a single test result is compared with a previ- Many optimal values for the strength ratio of
ously collected population data base, one should keep in mind the reciprocal muscle groups have been suggested in the litera-
that there is substantial variation in muscular performance with ture (16,52,56,77). Concerning the HQ ratio, the earliest re-
age, sex, body mass, activity level, and sports event, and, there- ports recommended that the optimal ratio should be between
fore, the used data base may give a misleading idea of how good 50% and 80% (2,10,17,52,56,58,77). None of them, however,
(or bad) the present test result is. In comparison of repeated test attempted to determine the relationship between HQ ratios and
results of the same individual, this kind of interpretation pro- long-term recovery from knee injury.
blem does not exist.
We made a series of studies with various types
In cross-sectional bilateral comparisons, it is of knee injuries trying to answer the above-mentioned question
usually assumed that symmetry is the norm and the comparison (31—33,37). The long-term recovery was evaluated with three
can be made. We should, however, remember that there are standardized knee scoring scales determining the subjective,

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exceptions, such as athletes involved in asymmetrical physical functional, clinical, and radiological outcome of the injured
activity (tennis). In addition, symmetry assumption may be knees. In every strength test, great intersubject variation of the
valid in the measurements of all major muscle groups in the HQ ratio was observed, even in the healthy knees. Follow-up
lower extremities but not for many muscle groups in the upper scores of the patient groups with low (<50%), optimal (50%—
extremities (21,67,71). 80%), or high (>80%) HQ ratios of the injured knees did not
differ significantly from each other. However, these scores were
In an ideal situation, proper data interpretation significantly better in patients whose injured knee HQ ratio was
of muscular performance might be able to give a reliable pre- nearly identical ( 15 %) rather than clearly different from
diction about musculoskeletal dysfunction and disability. Un- (<15 %) the uninjured knee. We concluded that HQ ratio was
disturbed function of human locomotor system depends, how- an idiosyncratic parameter and that it was unwise to give any
ever, on many factors other than muscular performance only recommendation about optimal HQ value for a single patient to
(neuromuscular coordination, joint motion and laxity, and intra- use as a goal for successful rehabilitation. For each patient, the
articular and extra-articular pathologies), and, therefore, quanti- most ideal HQ ratio of an injured extremity seemed to be the
tative determination of disability using muscle performance HQ ratio of the opposite, healthy extremity.
devices has been more or less unsuccessful (51,70, 75). Finally,
we should be able to interpret what the limit is between an Isokinetic devices in training and
abnormal and normal finding in an isokinetic test. Sapega (67) rehabilitation
suggests and the present author agrees that until valid data
become available, the following general guidelines are probably There is little doubt about the value of
reasonable in side-to-side comparison: isokinetic devices in scientific work. They have offered possi-
bilities to reliably measure muscle performance (strength,
1. When normal individuals are evaluated, imbalances in power, and endurance) isometrically at various joint angles as
strength of less than 10% can be considered normal, differ- well as isokinetically using various angular velocities. Our re-
ences of 10 %—20 % as possibly abnormal, and those greater search team, for example, has found isokinetic dynamometry
than 20% probably abnormal. very helpful in obtaining specific information about the
2. When one extremity is clearly expected to be weaker due to strength and power profile of knees with various types of
known disease or injury, 10 %—20 % difference can already chronic knee ligament insufficiencies (27,28,40,46), as well as
be considered probably abnormal, and those more than 20 % in determing with a randomized, controlled study design the
as almost certainly abnormal. effect of one-legged exercise on the strength, power, and en-
3. The commonly used criterion of 80 %—90 % of the measured durance of the contralateral leg (44).
capability in the uninvolved extremity can be used as a mi-
nimum standard for the involved extremity before the patient It is also clear that during the rehabilitation
returns to sports after the injury. process of a patient repeated, well standardized tests of muscle
performance using an isokinetic device will be beneficial. The
Reciprocal muscle group ratios only concern is the cost-benefit ratio of these devices, espe-
cially when it is a well known fact that much more inexpensive
The reciprocal muscle group ratio has been isometric cable tensiometers are accurate and reliable and seem
said to be an indicator of muscular balance or imbalance around to have no poorer ability to predict human functional capacity
the joint (4), and, it has been suggested, for example, that the than isokinetic devices (66,67).
S16 mt. J Sports Med. 15 (1994) P Kannus

The major problem with isokinetic devices total work in a 25-repetition test with a speed of 240 'Is) are the
concerns their usefulness as a training method of an athlete to best for use.
increase sporting performance, and, on the other hand, their
usefulness in rehabilitation of an injured patient. The problem Many internal and external factors in the
is that in natural movements of the human body, the angular isokinetic testing procedure can have an undesirable effect on
velocity is not constant throughout the range of motion of the the test result. However, through proper education and strict
joint. In normal movements, human muscle follows the so- adherence to the test instructions, it is possible to successfully
called stretch-shortening cycle in which the eccentric stretching control these confounding variables.
phase of the muscle-tendon unit (quadriceps unit while squat-
ting) is followed by concentric contraction (quadriceps unit In scientific work, isokinetic devices have
while jumping up from the squatting position) (50), and the greatly expanded the capacity for studying dynamic muscle
angular velocity changes along with the changing joint angle. function. There is also little doubt about their usefulness in
documenting the progress of muscular rehabilitation, although
Since isokinetic movement is "unnatural" and the cost-benefit ratio of isokinetic devices may be lower than
its training effect very specific, it is not a surprise that in many that of the inexpensive isometric dynamometers and cable ten-
countries healthy athletes and their coaches have not accepted siometers.
isokinetic training well in their training programs. Our ex-
perience with healthy sportsmen has been similar; improvement A major disadvantage of isokinetic devices is
in isokinetic performance has not guaranteed improved athletic that isokinetic movement is unnatural and that the training ef-
performance in jumping, throwing, or sprinting. fect received by the trained muscles is very, although not en-
tirely, specific to that type of movement. In other words,
In patient rehabilitation, isokinetic training ma- isokinetic performance capacity cannot accurately predict or
chines became very popular in the 1980s (19,38). Their major guarantee the functional capacity of the subject in actual human

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benefit was that in some specific joint problems such as chon- performance tasks such as jumping, throwing, or sprinting. In
dromalacia patefiae, the dynamometer could accomodate to the addition, being normally an isolated joint exercise instead of
decreased force applied at the point of pain and reduce the using the whole kinetic chain, isokinetic movements may pro-
resistance. Recept research results demonstrate, however, that duce large loads on the involved joints and may, therefore, be
for example isokinetic knee extension exercise, which is a typi- under certain conditions dangerous for healing tissues. Also, it
cal example of effective isolated one-joint exercise (open should be kept in mind that isokinetic exercise does not offer a
kinetic chain exercise), produces large loads on the involved possibility for simultaneous training of proprioception, balance,
joints (compression) and ligaments (stress) (49,57) and may, and coordination.
therefore, be dangerous for healing tissues, especially for heal-
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