Quadriceps and Patient-Reported Function in ACL-Reconstructed Patients: A Principal Component Analysis

in Journal of Sport Rehabilitation
Restricted access

Purchase article

USD  $24.95

Student 1 year subscription

USD  $74.00

1 year subscription

USD  $99.00

Student 2 year subscription

USD  $141.00

2 year subscription

USD  $185.00

Context: Assessment of physical function for individuals after anterior cruciate ligament reconstruction (ACL-R) is complex and warrants the use of diverse evaluation strategies. To maximize the efficiency of assessment, there is a need to identify tests that provide the most meaningful information about this population. Objective: To investigate underlying constructs of quadriceps muscle function that uniquely describe aspects of performance in patients after ACL-R and establish clinical thresholds for measures able to classify patients with and without ACL-R. Design: Cross-sectional. Setting: Research laboratory. Patients (or Other Participants): Seventy-two patients with a primary, unilateral ACL-R (32 males and 40 females, age = 26.0 [9.3] y, time since surgery = 46.5 [58.0] mo) and 30 healthy controls (12 males and 18 females, age = 22.7 [4.6] y). Intervention(s): Quadriceps function was assessed bilaterally during 1 study visit. Main Outcome Measures: Isokinetic strength (peak torque, total work, and average power) at 90° and 180°/s, maximal voluntary isometric contraction torque, fatigue index, central activation ratio, Hoffmann reflex, and active motor threshold. Principal component analyses were performed for the involved limb, contralateral limb, and limb symmetry. Receiver–operator characteristic curve analyses were conducted to determine the diagnostic utility of each variable. Binary logistic regression was used to predict group membership (ACL-R vs healthy). Results: Three components of peripheral, central, and combined (peripheral and central) muscle function were identified, explaining 70.7% to 80.5% of variance among measures of quadriceps function. Total knee-extensor work at 90°/s (≥18.4 J/kg), active motor threshold (≥39.5%), and central activation ratio (≥94.7%) of the involved limb were strong predictors of patient status and correctly classified 83.5% of patients with ACL-R (P < .001). Conclusions: Unique constructs of peripheral, central, and combined muscle function exist in patients with ACL-R. Total knee-extensor work at 90°/s, active motor threshold, and central activation ratio consistently explained a significant portion of variance in measures of quadriceps function, demonstrated acceptable to excellent diagnostic utility, and predicted group membership with 72.8% to 83.5% accuracy.

Norte is with Athletic Training Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA. Hertel, Saliba, and Hart are with Sports Medicine Program, Department of Kinesiology, University of Virginia, Charlottesville, VA, USA. Hertel, Saliba, Diduch, and Hart are with Sports Medicine Division, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.

Norte (grant.norte@utoledo.edu) is corresponding author.
  • 1.

    Lynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. 2015;49(5):335342. doi:10.1136/bjsports-2013-092299

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Logerstedt D, Arundale A, Lynch A, Snyder-Mackler L. A conceptual framework for a sports knee injury performance profile (SKIPP) and return to activity criteria (RTAC). Braz J Phys Ther. 2015;19(5):340359. doi

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(12):16971705. PubMed ID: 22137326 doi:10.1016/j.arthro.2011.09.009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Zwolski C, Schmitt LC, Quatman-Yates C, Thomas S, Hewett TE, Paterno MV. The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2015;43:22422249. PubMed ID: 26183172 doi:10.1177/0363546515591258

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE. Strength asymmetry and landing mechanics at return to sport after anterior cruciate ligament reconstruction. Med Sci Sports Exerc. 2015;47(7):14261434. PubMed ID: 25373481 doi:10.1249/MSS.0000000000000560

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC. Young athletes with quadriceps femoris strength asymmetry at return to sport after anterior cruciate ligament reconstruction demonstrate asymmetric single-leg drop-landing mechanics. Am J Sports Med. 2015;43(11):27272737. PubMed ID: 26359376 doi:10.1177/0363546515602016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2012;42(9):750759. PubMed ID: 22813542 doi:10.2519/jospt.2012.4194

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Palmieri-Smith RM, Lepley LK. Quadriceps strength asymmetry after anterior cruciate ligament reconstruction alters knee joint biomechanics and functional performance at time of return to activity. Am J Sports Med. 2015;43(7):16621669. PubMed ID: 25883169 doi:10.1177/0363546515578252

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Kuenze C, Hertel J, Saliba S, Diduch DR, Weltman A, Hart JM. Clinical thresholds for quadriceps assessment after anterior cruciate ligament reconstruction. J Sport Rehabil. 2015;24(1):3646. PubMed ID: 25203517 doi:10.1123/jsr.2013-0110

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Urbach D, Nebelung W, Weiler HT, Awiszus F. Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear. Med Sci Sports Exerc. 1999;31(12):16911696. PubMed ID: 10613416 doi:10.1097/00005768-199912000-00001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010;40(3):250266. PubMed ID: 19954822 doi:10.1016/j.semarthrit.2009.10.001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010;45(1):8797. PubMed ID: 20064053 doi:10.4085/1062-6050-45.1.87

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Grevnerts HT, Terwee CB, Kvist J. The measurement properties of the IKDC-subjective knee form. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):36983706. PubMed ID: 25193574 doi:10.1007/s00167-014-3283-z

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28(2):8896. PubMed ID: 9699158 doi:10.2519/jospt.1998.28.2.88

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum. 2001;45(5):453461. PubMed ID: 11642645 doi:10.1002/1529-0131(200110)45:5<453::AID-ART365>3.0.CO;2-W

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    French DJ, France CR, Vigneau F, French JA, Evans RT. Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK). Pain. 2007;127(1-2):4251. PubMed ID: 16962238 doi:10.1016/j.pain.2006.07.016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Selim AJ, Rogers W, Qian SX, Brazier J, Kazis LE. A preference-based measure of health: the VR-6D derived from the veterans RAND 12-Item Health Survey. Qual Life Res. 2011;20(8):13371347. PubMed ID: 21336657 doi:10.1007/s11136-011-9866-y

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37(5):890897. PubMed ID: 19261899 doi:10.1177/0363546508330143

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Amireault S, Godin G. The Godin-Shephard leisure-time physical activity questionnaire: validity evidence supporting its use for classifying healthy adults into active and insufficiently active categories. Percept Mot Skills. 2015;120(2):604622. PubMed ID: 25799030 doi:10.2466/03.27.PMS.120v19x7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Rossi S, Hallett M, Rossini PM, Pascual-Leone A, Safety of TMSCG. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol. 2009;120(12):20082039. PubMed ID: 19833552 doi:10.1016/j.clinph.2009.08.016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Kuenze CM, Hertel J, Weltman A, Diduch D, Saliba SA, Hart JM. Persistent neuromuscular and corticomotor quadriceps asymmetry after anterior cruciate ligament reconstruction. J Athl Train. 2015;50:303312. PubMed ID: 25622244 doi:10.4085/1062-6050-49.5.06

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Norte GE, Saliba SA, Hart JM. Immediate effects of therapeutic ultrasound on quadriceps spinal reflex excitability in patients with knee injury. Arch Phys Med Rehabil. 2015;96(9):15911598. PubMed ID: 25839089 doi:10.1016/j.apmr.2015.03.014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Merletti R, Hermens H. Introduction to the special issue on the SENIAM European concerted action. J Electromyogr Kinesiol. 2000;10(5):283286. PubMed ID: 11018437 doi:10.1016/S1050-6411(00)00019-5

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Roberts D, Kuenze C, Saliba S, Hart JM. Accessory muscle activation during the superimposed burst technique. J Electromyogr Kinesiol. 2012;22(4):540545. PubMed ID: 22321959 doi:10.1016/j.jelekin.2012.01.008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Hart JM, Fritz JM, Kerrigan DC, Saliba EN, Gansneder BM, Ingersoll CD. Reduced quadriceps activation after lumbar paraspinal fatiguing exercise. J Athl Train. 2006;41(1):7986. PubMed ID: 16619099

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Kent-Braun JA, Le Blanc R. Quantitation of central activation failure during maximal voluntary contractions in humans. Muscle Nerve. 1996;19(7):861869. PubMed ID: 8965840 doi:10.1002/(SICI)1097-4598(199607)19:7<861::AID-MUS8>3.0.CO;2-7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Surakka J, Romberg A, Ruutiainen J, Virtanen A, Aunola S, Maentaka K. Assessment of muscle strength and motor fatigue with a knee dynamometer in subjects with multiple sclerosis: a new fatigue index. Clin Rehabil. 2004;18(6):652659. PubMed ID: 15473117 doi:10.1191/0269215504cr781oa

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Groppa S, Oliviero A, Eisen A, et al. A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee. Clin Neurophysiol. 2012;123(5):858882. PubMed ID: 22349304 doi:10.1016/j.clinph.2012.01.010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Gandevia SC. Spinal and supraspinal factors in human muscle fatigue. Physiol Rev. 2001;81(4):17251789. PubMed ID: 11581501 doi:10.1152/physrev.2001.81.4.1725

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Undheim MB, Cosgrave C, King E, et al. Isokinetic muscle strength and readiness to return to sport following anterior cruciate ligament reconstruction: is there an association? A systematic review and a protocol recommendation. Br J Sports Med. 2015;49(20):13051310. PubMed ID: 26105017 doi:10.1136/bjsports-2014-093962

    • Crossref
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 268 241 19
Full Text Views 29 28 3
PDF Downloads 14 13 2