Journal of Orthopaedic & Sports Physical Therapy
2001;31(2) :96-100
Biomechanical Basis for Stability: An
Explanation to Enhance Clinical-Utility
Stuart M. McGill, PhD
lacek Cholewicki, PhD2
The term "stability," as used in the field of biome-
chanics, remains undefined in many clinical cases.
This fact can impede the design of therapies intend-
Downloaded from www.jospt.org at on March 27, 2014. For personal use only. No other uses without permission.
ed to enhance joint stability. In fact, Fritz et a1,6 in a
review on lumbar instability, concluded that "At pres-
ent, much controversy exists regarding the proper
definition of the condition, the best diagnostic meth-
ods, and the most efficacious treatment approaches."
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Some progress has been made in the biomechanics
field toward the formulation and implementation of
stability in musculoskeletal linkages and joints.
The purpose of this review is to synthesize and in-
terpret the biomechanical foundation for stability
while avoiding mathematical complexity, to demon-
strate the notion of stability using specific musculo-
skeletal examples, and to propose the next logical
steps to full utilization of the stability concept for o p
timal rehabilitation. This review is not intended as a
Journal of Orthopaedic & Sports Physical Therapy®
scholarly treatise but rather as a short commentary
aimed at providing clinicians with a vantage point for
making clinical decisions. Finally, because we are
spine biomechanists, and because the original work
defining the mechanics of stability of musculoskeletal
systems used the spine as an example, this article em-
phasizes the spine in its examples.
In the late 1980's. Anders Bergmark, a professor of
solid mechanics at the University of Lund in Sweden,
elegantly formalized stability in a muscular system.
Using a spine model' with joint stiffness and 40 mus-
cles, he formalized mathematically the concepts of
energy wells, stiffness, stability, and instability. For the
most part, this classic work went unrecognized, large-
ly because the engineers who understood its mechan-
I Faculty of Applied Health Sciences, Department of Kinesiology, Univer- flat surface or at the top of a hill (an upside down
sity of Waterloo, Waterloo, Ontario, Canada.
Department of Orthopaedics and Rehabilitation, Yale University School the ball to roll away. Thus, the objective in creating
of Medicine, New Haven, Conn.
Send correspondence to Stuart McCill, Faculty ofApplied Health Sciences, stability with this analogy is to create a "bowl-
Department of Kinesiology, University of Waterloo,200 UniversityAvenue, shaped" potential energy surface, or an energy well.
Waterloo, Ontario N2L 3G 1, Canada. E-mail: mcgill@healthyuwaterloo.ca The ball will seek the position of minimum potential
ics lacked the biological/clinical perspective, and the
relatively complex mathematics thwarted its wide-
spread use in clinics. Subsequent to Bergmark's ef-
forts, several groups have added sophistication to the
formalization of joint stability. An explanation of the
theory requires 4 steps.
Potential Energy
The foundation of stability begins with the concept
of potential energy which, for our purposes, takes 2
basic forms. In the first form, objects (with mass)
have potential energy by virtue of their height above
a datum. An apple has potential energy while still on
the tree because this energy would be transformed
into kinetic energy if it were to fall.
potential energy = mass*gravitational con-
stant*height
In the second form, elastic bodies may possess po-
tential energy by virtue of their elastic deformation
under load, storing potential energy which is recov-
ered when the load is removed (such as what h a p
pens when an elastic band is loaded and unloaded).
The first form of potential energy describes the no-
tions of "energy wells" and "minimum" potential
energy. If a ball is placed into a bowl it is stable. This
is true because if one were to apply a small force to
the ball (or a perturbation) the ball would roll up
the side of the bowl but then come to rest again in
the position of least potential energy-the bottom of
the bowl. This system can be made more stable by ei-
ther deepening the bowl or increasing the steepness
of its sides (Figure 1). Conversely, a ball placed on a
bowl) is unstable since any perturbation would cause
 FIGURE 1. The ball in the bowl seeks the "energy well" or position of minimum potential energy (mgh). Deepeningthe bowl or increasing the steepness
of the sides increases stability.
energy (or mass multiplied by gravity and height-
height being the variable to minimize). This corre-
sponds to a stable situation, but just how stable is it?
The quantification of stability requires specification
of an unperturbed state or the amount of residual
potential energy and a study of the system perturbed
by a force (which does work).
The previous analogy is a 2dimensional example
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(allowing motion in a single plane). This would be
analogous to a hinged skeletal joint that only has the
capacity for flexion/extension. Some ball and socket
joints can rotate in 3 planes (3 degrees of freedom),
requiring a 4-dimensional bowl. The lumbar spine,
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
for example, has 5 segmental joints, each able to r e
tate in 3 planes, for a total of 15 degrees of freedom
and a bowl with more than 15 dimensions. Unstable
spinal joints may also shear or translate, adding an-
other 3 degrees of freedom per joint and resulting
in more than 30 dimensions to the bowl. Obviously,
this is a theoretical bowl since a real bowl has only 3
dimensions; mathematics allows us to examine a 30-
dimensional bowl. If the height of the bowl was de-
Journal of Orthopaedic & Sports Physical Therapy®
creased in any one of the 30 dimensions, the ball
would roll out. In clinical terms, there are many ana-
tomical structures responsible for maintaining the
"height" of the bowl for each dimension.
FIGURE 2. Whole bdy stability is increased by increasing the mass, low- to a lesser degree, by placing
ering the height of the mass, or widening the base of support. A larger
value of " 0 , which is modulated by the base width and mass position,
increases the ability to survive a pertubation (P)and therefore is more tor control system leads to inappropriate magnitudes
stable.
J Orthop Sports Phys Ther .Volume 31 Number 2 .February 2001
Whole Body Stability
Whole body stability can be briefly addressed to il-
lustrate the breadth of the concept. Consider the
mass within the base of support (Figure 2). The sys-
tem is considered stable if it would survive a minor
perturbation applied to the top of the cone. A larger
perturbation is required to cause the cone to rotate
over 1 support, raising the potential energy to the
point where the center of mass falls outside the base
of support into a region of instability (or 8 = 0 de-
grees in Figure 2). A larger "0" deepens the poten-
tial energy well. Thus, stability in the rigid whole
body example is enhanced only by increasing the
mass, widening the base of support, or lowering the
center of mass.
Elastic Energy and Stiffness
Having considered the analogies incorporating p e
tential energy by virtue of height, potential energy
can be considered as a function of stiffness and stor-
age of elastic energy, which is much more useful for
musculoskeletal application. Elastic potential energy
can be calculated from the formula:
potential energy = 1/2*k*xa2
where an elastic structure having stiffness (k) stores
potential energy by virtue of it being stretched a dis-
tance (x). In other words the greater the stiffness,
the greater the steepness of the sides of the bowl
(from the previous analogy), and the more stable the
structure. Thus stiffness creates stability (Figure 3).
Active muscle creates tendon force but also produces
a stiff member and, in fact, the greater the activation
of the muscle, the greater this stiffness. Furthermore,
joints possess inherent joint stiffness, as ligaments
and other capsular structures contribute stiffness that
increases towards the boundary of joint motion. In
this way, the motor control system can control stabili-
ty of the joints through active muscle activation and,
in positions that
passive stiffness A
of muscle force and stiffness, allowing a "valley" for
97
 vation, amplitude, or timing can produce instability
or unstable behavior at lower applied loads.

Sufficient Stability
Clinicians are qualitatively very aware of patients
who cocontract their muscles in order to stabilize a
joint; this type of behavior makes sense and is, in
fact, the only way to stabilize a joint. However, the
clinical question then becomes how much stability is
necessary. Obviously insufficient stiffness is problem-
atic, but too much stiffness is equally so. What is
"sufficient stability"?
For a joint to bear larger loads, more stability is re-
quired to prevent buckling or unwanted displace-
ment. However, in most situations only a modest
amount of stiffness is required to stabilize the joint
and in fact, maximal joint stiffness can be achieved
during contractions as low as 25% of a maximum iso-
metric c o n t r a c t i ~ nToo
. ~ much stiffness from muscle
FIGURE 3. Increasing the stiffness of the cables (muscles) increases the activation imposes a severe load on the joint,1° caus-
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ability to support larger applied loads (P) without falling.
the "ball to roll out," or orthopaedically, for a joint
to buckle or undergo shear translation.
In a complex system such as the lumbar spine,
Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ing it to become overly stiff and thus impede mo-
tion. In the midrange of motion, the motor control
system allocates muscle activation patterns to ensure
that appropriate stability is achieved.12 Individual
joints have passive stiffness that increases towards the

quantification of the amount of stability can be lik- joint end range. If the joint is not at the end range
ened to analysis of the bowl, which may have many and passive tissues cannot create a mechanical stop
degrees of freedom and dimensions. Ignoring the to motion, it has been argued that the role of the
mathematical details, this is done by forming a ma- motor system is to first add sufficient stiffness and
trix where the total stiffness and potential energy of ensure joint stability before torque generation. Post
each joint degree of freedom, or dimension, is repre- injury, losses in normal motor patterns have been
sented by a number (or eiganvalue), and the magni- documented (well summarized in Richardson et
tude of that number represents the height of the all4),as have losses of normal passive stiffness and re-
bowl in that particular dimension. A small mathemat- sultant aberrant joint motion.' The biomechanist's
Journal of Orthopaedic & Sports Physical Therapy®

ical perturbation is then performed which does
"work" on the joint. The joules of work from the
perturbation is subtracted from the joules of poten-
tial energy of the structure (which equals the eigen-
value for any degree of freedom) and any eigenvalue est amount of "extra" stiffness/stability to form a
less than 0 indicates instability. The challenge, then,
is to identify the "eigenvector" to reveal the mode in ty."
which the instability occurred and the anatomical
candidates at fault, which then become targets of
therapy and prophylactic strategies.
The link between muscle activation and stiffness is
an important concept. Activating a muscle increases
stiffness, both within the muscle and to the joint(s) it sights into the pathogenesis of injury. For example, it
crosses. Activating a group of muscle synergists and
antagonists in the optimal way now becomes a criti-
cal issue. From a motor control point of view, the
analogy of an orchestra may be used: The orchestra
must play together and each instrument must pro-
duce a controlled volume, or in clinical terms, the
full complement of the stabilizing musculature must
work coherently to achieve stability (Figure 4). One
instrument with insufficient volume or timing can
ruin the sound; one muscle with inappropriate acti-
contribution is to quantify the loss of passive tissue
stiffness and determine how much muscular stiffness
(both magnitude and pattern) is necessary for stabili-
ty. Clinical objectives require the addition of a mod-
margin of safety; this is known as "sufficient stabili-
Clinical Implications
The conceptualization of stability presented here
can help justify certain therapies and provide new in-
is now possible to explain how people can sustain a
back injury from a task such as picking up a pencil.
In this situation, the general demand of the task is
relatively low, as are muscular forces and stiffness. If
the motor system committed a small error in the ac-
tivation sequence, muscle magnitudes, or both, and
resulted in a temporary loss of stiffness in a single
mode from a single muscle, instability could result.
That is, the ball would roll out through the side of
the bowl to which that particular muscle contributed

J Orthop Sports Phys Ther.Volume 31 .Number 2.Febmary 2001

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Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 4. Spine stiffness is achieved by a complex interaction of stiffening stnlctures along the spine (left panel) and those forming the torso (right
panel).
Journal of Orthopaedic & Sports Physical Therapy®
stiffness (the walls are created not by single muscles
but by a system of muscles that effect, or act, in that
particular direction of joint motion). The resulting
rotation or translation at the joint overloads a passive
tissue to the point of damage. In fact, such an insta-
bility was observed in an experiment that collected
videoflouroscope records from power lifters lifting
heavy loads where a single spine motion segment
buckling occurred that resulted in injury."he dam-
aged joint subsequently loses passive stiffness, possi-
bly causing buckling at even lower loads in the fu-
ture. This conceptualization of stability is beginning
to provide clinicians with specific target levels of
muscle activation necessary to achieve sufficient sta-
bility. The levels of activation observed by Cholewicki
and McGil14 and Cholewicki et a15 have demonstrated
that sufficient stability of the lumbar spine is
achieved (with the spine in a neutral curvature) in
most people with modest levels of coactivation of the
muscles forming the abdominal wall (at least below
10% of maximum isometric contraction). While large
muscular forces are rarely required, it appears that
success in daily activities requires relatively low levels
J Orthop Sports Phys Ther-Volume 31 Number 2. Februa~y2001
0
--I
m
of activation maintained for long periods of time. Pa-
tient management requires further thought as tissue
injury alters the amount of stability required. An in-
jury causing inherent losses in passive tissue stiffness
(specifically disc or ligament) results in joint laxity1s
that necessitates higher levels of muscular activation/
stiffness to ensure sufficient ~tability.~."Examples of
specific stabilization exercises have been quantified
and ranked for muscle activation magnitudes togeth-
er with the resultant spine load as summarized by
McGill." Functionally, a patient must be able to
maintain sufficient stability during necessary daily ac-
tivities: getting on and off the toilet, in and out of
the car, up and downstairs, etc. "Sufficient stability"
in these examples results from light cocontraction of
the stabilizing musculature. This proposition suggests
that the margin of safety when performing tasks, par-
ticularly the tasks of daily living, is not compromised
by insufficient strength but rather points to the im-
portance of endurance. Epidemiological evidence
suggests that strong abdominals may not provide the
prophylactic effect that had been hoped for. Recent
 work suggests that endurable muscles reduce the risk
of future back trouble^.^.^
While basic science has underscored the need for
an anatomical system to be stable before it is present-
ed with a physical challenge, the clinical technique
for doing so continues to be developed.15 Clinical
questions to be addressed include identifying how
the various components of the anatomy at particular
joints contribute to stability and the ideal ways to en-
hance their contribution; what magnitudes of muscle
activation are required to achieve sufficient stability
in a wide variety of tasks and type of patients; what
are the best methods to reeducate faulty motor con-
trol systems to both achieve sufficient stability and re-
duce the risk of inappropriate motor patters occur-
ring in the future? Addressing mobility problems
from the perspective of "sufficient stability" requires
a team approach. It is a unifying concept that can
enable clinicians, biomechanistsengineers, physiolo-
gists, and anatomists to collectively tackle the mobili-
ty problems that are so important for quality of life.
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chanical engineering. Acta Orthop Scand. 1989;60:3-53.
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2. Biering-Sorensen F. Physical measurements as risk indi-
cators for low-back trouble over a one-year period. Spine.
3. Cholewicki J, McGill S. Lumbar posterior ligament in-
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 2001 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®