Quadriceps and Hamstring Strength Symmetry After Anterior Cruciate Ligament Reconstruction: A Prospective Study

in Journal of Sport Rehabilitation
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Objectives: To evaluate change in involved and uninvolved quadriceps and hamstring strength and limb symmetry indices (LSI) in regular intervals over the first 6 months following anterior cruciate ligament reconstruction (ACLR). Design: Prospective cohort study. Participants: Thirty-eight male participants (mean age: 24.2 [6.4] y, mean body mass index: 23.6 [4.2] kg/m2), who underwent ACLR were included. Main Outcome Measures: Isometric strength testing of the quadriceps and hamstring muscles was performed at 1, 2, 3, and 6 months after ACLR. Quadriceps and hamstring peak torques for each limb and LSI were calculated. Repeated-measures analysis of covariance and paired t tests were used to evaluate changes in strength over time and between limbs, respectively. Results: Quadriceps and hamstring peak torques of the involved limb consistently increased between each time point from 1 to 6 months (P < .001 and P = .01, respectively), whereas the uninvolved limb values did not change after ACLR (P > .05). In addition, uninvolved limb peak torque values were higher than involved limb values at each time point after ACLR for both the quadriceps and hamstrings (all P < .01). At 6 months after ACLR, 28.9% of participants demonstrated LSI greater than 90% for quadriceps strength, 36.8% demonstrated LSI greater than 90% for hamstring strength, and 15.8% of participants demonstrated greater than 90% LSI for both quadriceps and hamstring strength. Conclusions: Participants demonstrated a consistent increase in quadriceps and hamstring strength of the involved limb, with no notable change in uninvolved limb strength over the 6 months after ACLR. However, at 6 months after ACLR, only approximately 16% of participants demonstrated both quadriceps and hamstring strength LSI greater than 90%, the typically recommended cutoff value for return to sport.

Harput and Tunay are with the Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey. Ithurburn is with the Department of Physical Therapy and Center for Exercise Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA.

Harput (gulcan.aktas@hacettepe.edu.tr) is corresponding author.
  • 1.

    Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med. 2005;33(10):15791602. PubMed ID: 16199611 doi:

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

    Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K. A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy. 2007;23(12):13201325.e6. PubMed ID: 18063176 doi:

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

    Noll S, Garrison JC, Bothwell J, Conway JE. Knee extension range of motion at 4 weeks is related to knee extension loss at 12 weeks after anterior cruciate ligament reconstruction. Orthop J Sports Med. 2015;3(5):2325967115583632. PubMed ID: 26675061 doi:

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

    Goodwillie AD, Shah SS, McHugh MP, Nicholas SJ. The effect of postoperative KT-1000 arthrometer score on long-term outcome after anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(7):15221528. PubMed ID: 28277739 doi:

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

    Ardern CL, Webster KE. Knee flexor strength recovery following hamstring tendon harvest for anterior cruciate ligament reconstruction: a systematic review. Orthop Rev. 2009;1(2):e12. PubMed ID: 21808674 doi:

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

    Thomee R, Neeter C, Gustavsson A, et al. Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20(6):11431151. PubMed ID: 22314862 doi:

    • 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:

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

    Toole AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, Schmitt LC. Young athletes cleared for sports participation after anterior cruciate ligament reconstruction: how many actually meet recommended return-to-sport criterion cutoffs? J Orthop Sports Phys Ther. 2017;47(11):825833. PubMed ID: 28990491

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

    Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L. Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):859868. PubMed ID: 22349604 doi:

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

    Abourezk MN, Ithurburn MP, McNally MP, et al. Hamstring strength asymmetry at 3 years after anterior cruciate ligament reconstruction alters knee mechanics during gait and jogging. Am J Sports Med. 2017;45(1):97105. PubMed ID: 27590173 doi:

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

    Gokeler A, Welling W, Zaffagnini S, Seil R, Padua D. Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):192199. PubMed ID: 27423208 doi:

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

    Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804808. PubMed ID: 27162233 doi:

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

    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. PubMed ID: 23881894 doi:

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

    Chung KS, Ha JK, Yeom CH, et al. Are muscle strength and function of the uninjured lower limb weakened after anterior cruciate ligament injury? Two-year follow-up after reconstruction. Am J Sports Med. 2015;43(12):30133021. PubMed ID: 26460100 doi:

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

    Wellsandt E, Failla MJ, Snyder-Mackler L. Limb symmetry indexes can overestimate knee function after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2017;47(5):334338. PubMed ID: 28355978 doi:

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

    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:

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

    Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC. Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):426433. PubMed ID: 28918506 doi:

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

    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:

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

    Harput G, Kilinc HE, Ozer H, Baltaci G, Mattacola CG. Quadriceps and hamstring strength recovery during early neuromuscular rehabilitation after ACL hamstring-tendon autograft reconstruction. J Sport Rehabil. 2015;24(4):398404. PubMed ID: 26633588 doi:

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

    American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2009;41(3):687708. doi:

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

    Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2010;40(11):705721. PubMed ID: 20710097 doi:

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

    Morrissey MC, Drechsler WI, Morrissey D, Knight PR, Armstrong PW, McAuliffe TB. Effects of distally fixated versus nondistally fixated leg extensor resistance training on knee pain in the early period after anterior cruciate ligament reconstruction. Phys Ther. 2002;82(1):3543. PubMed ID: 11784276 doi:

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

    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(9):22422249. PubMed ID: 26183172 doi:

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

    Keays SL, Bullock-Saxton J, Keays AC, Newcombe P. Muscle strength and function before and after anterior cruciate ligament reconstruction using semitendonosus and gracilis. Knee. 2001;8(3):229234. PubMed ID: 11706731 doi:

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

    Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med. 2008;27(3):405424. PubMed ID: 18503875 doi:

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

    Grapar Zargi T, Drobnic M, Vauhnik R, Koder J, Kacin A. Factors predicting quadriceps femoris muscle atrophy during the first 12weeks following anterior cruciate ligament reconstruction. Knee. 2017;24(2):319328. PubMed ID: 27923622 doi:

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

    Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Knee strength deficits after hamstring tendon and patellar tendon anterior cruciate ligament reconstruction. Med Sci Sports Exerc. 2000;32(8):14721479. doi:

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

    Wright RW, Haas AK, Anderson J, et al. Anterior cruciate ligament reconstruction rehabilitation: MOON guidelines. Sports Health. 2015;7(3):239243. PubMed ID: 26131301 doi:

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

    Andrade R, Pereira R, van Cingel R, Staal JB, Espregueira-Mendes J. How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II) [published online ahead of print June7, 2019]. Br J Sports Med. doi:

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

    Mirkov DM, Knezevic OM, Maffiuletti NA, Kadija M, Nedeljkovic A, Jaric S. Contralateral limb deficit after ACL-reconstruction: an analysis of early and late phase of rate of force development. J Sports Sci. 2017;35(5):435440. PubMed ID: 27043874 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Pairot de Fontenay B, Argaud S, Blache Y, Monteil K. Contralateral limb deficit seven months after ACL-reconstruction: an analysis of single-leg hop tests. Knee. 2015;22(4):309312. PubMed ID: 25981951 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft. Clin Biomech. 2007;22(5):543550. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Benjaminse A, Holden S, Myer GD. ACL rupture is a single leg injury but a double leg problem: too much focus on ‘symmetry’ alone and that’s not enough! Br J Sports Med. 2018;52(16):10291030. PubMed ID: 29519886 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Gokeler A, Welling W, Benjaminse A, Lemmink K, Seil R, Zaffagnini S. A critical analysis of limb symmetry indices of hop tests in athletes after anterior cruciate ligament reconstruction: a case control study. Orthop Traumatol Surg Res. 2017;103(6):947951. PubMed ID: 28428033 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Harput G, Soylu AR, Ertan H, Ergun N, Mattacola CG. Effect of gender on the quadriceps-to-hamstrings coactivation ratio during different exercises. J Sport Rehabil. 2014;23(1):3643. PubMed ID: 24084227 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    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:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Burgi CR, Peters S, Ardern CL, et al. Which criteria are used to clear patients to return to sport after primary ACL reconstruction? A scoping review. Br J Sports Med. 2019;53(18):11541161. PubMed ID: 30712009 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Raoul T, Klouche S, Guerrier B, et al. Are athletes able to resume sport at six-month mean follow-up after anterior cruciate ligament reconstruction? Prospective functional and psychological assessment from the French Anterior Cruciate Ligament Study (FAST) cohort. Knee. 2019;26(1):155164. PubMed ID: 30473373 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Barfod KW, Feller JA, Hartwig T, Devitt BM, Webster KE. Knee extensor strength and hop test performance following anterior cruciate ligament reconstruction. Knee. 2019;26(1):149154. PubMed ID: 30554909 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    van Melick N, van Cingel RE, Brooijmans F, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016;50(24):15061515. PubMed ID: 27539507 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41.

    Krych AJ, Woodcock JA, Morgan JA, Levy BA, Stuart MJ, Dahm DL. Factors associated with excellent 6-month functional and isokinetic test results following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):10531059. PubMed ID: 24531355 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Huber R, Viecelli C, Bizzini M, et al. Knee extensor and flexor strength before and after anterior cruciate ligament reconstruction in a large sample of patients: influence of graft type. Phys Sportsmed. 2019;47(1):8590. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43.

    Welling W, Benjaminse A, Seil R, Lemmink K, Zaffagnini S, Gokeler A. Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatol Arthrosc. 2018;26(12):36363644. PubMed ID: 29574548 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Herrington L, Ghulam H, Comfort P. Quadriceps strength and functional performance after anterior cruciate ligament reconstruction in professional soccer players at time of return to sport [published online ahead of print August 17, 2018]. J Strength Cond Res. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Novaretti JV, Franciozi CE, Forgas A, Sasaki PH, Ingham SJM, Abdalla RJ. Quadriceps strength deficit at 6 months after ACL reconstruction does not predict return to preinjury sports level. Sports Health. 2018;10(3):266271. PubMed ID: 29485941 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Sousa PL, Krych AJ, Cates RA, Levy BA, Stuart MJ, Dahm DL. Return to sport: does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes? Knee Surg Sports Traumatol Arthrosc. 2017;25(5):13561363. PubMed ID: 26205480 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Kuenze CM, Foot N, Saliba SA, Hart JM. Drop-landing performance and knee-extension strength after anterior cruciate ligament reconstruction. J Athl Train. 2015;50(6):596602. PubMed ID: 25978101 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Li G, Rudy TW, Sakane M, Kanamori A, Ma CB, Woo SL. The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL. J Biomech. 1999;32(4):395400. PubMed ID: 10213029 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

    Weinhandl JT, Earl-Boehm JE, Ebersole KT, Huddleston WE, Armstrong BS, O’Connor KM. Reduced hamstring strength increases anterior cruciate ligament loading during anticipated sidestep cutting. Clin Biomech. 2014;29(7):752759. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50.

    Withrow TJ, Huston LJ, Wojtys EM, Ashton-Miller JA. Effect of varying hamstring tension on anterior cruciate ligament strain during in vitro impulsive knee flexion and compression loading. J Bone Joint Surg Am. 2008;90(4):815823. PubMed ID: 18381320 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51.

    Kuenze C, Pietrosimone B, Lisee C, et al. Demographic and surgical factors affect quadriceps strength after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(3):921930. PubMed ID: 30327821 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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