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Pier Paolo Mariani, Luca Laudani, Jacopo E. Rocchi, Arrigo Giombini, and Andrea Macaluso

Context: All rehabilitative programs before anterior cruciate ligament (ACL) reconstructive surgery, which are focused on recovery of proprioception and muscular strength, are defined as prehabilitation. While it has shown that prehabilitation positively affects the overall outcome after ACL reconstruction, it is still controversial whether preoperatively enhancing quadriceps strength has some beneficial effect on postoperative strength, mainly during the first period. Objective: To determine whether there is any relationship between preoperative and early postoperative quadriceps strength. Design: Case control. Setting: University research laboratory. Participants: Fifty-nine males (18–33 y; age: 23.69 [0.71] y) who underwent ACL reconstruction with patellar-tendon autograft were examined the day before surgery, and at 60 and 90 days after surgery. Main Outcome Measures: The limb symmetry index (LSI) was quantified for maximal voluntary isometric contraction of the knee extensor muscles and of the knee flexor muscles at 90° joint angle. A k-means analysis was performed on either quadriceps or hamstrings LSI before surgery to classify the patients in high and low preoperative LSI clusters. Differences in postoperative LSI were then evaluated between the high and low preoperative LSI clusters. Results: Following surgery, there were no differences in the quadriceps LSI between patients with high and low preoperative quadriceps LSI. Sixty days after surgery, the hamstrings LSI was higher in patients with high than low preoperative hamstrings LSI (84.0 [13.0]% vs 75.4 [15.9]%; P < .05). Conclusions: Findings suggest that quadriceps strength deficit is related to the ACL injury and increases further after the reconstruction without any correlation between the preoperative and postoperative values. Therefore, it appears that there is no need to delay surgery in order to increase the preoperative quadriceps strength before surgery.

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Tania Suarez, Luca Laudani, Arrigo Giombini, Vincenzo Maria Saraceni, Pier Paolo Mariani, Fabio Pigozzi, and Andrea Macaluso


Tearing of the anterior cruciate ligament (ACL) may disrupt the ability to recognize the knee position in space during limb-repositioning tasks, which is referred to as joint-position sense (JPS). Impairments in JPS have been shown to be lower during active than passive repositioning tasks, thus suggesting that coactivation patterns of the muscles surrounding the knee might compensate for the disrupted JPS and ensure accurate limb repositioning in ACL-deficient individuals.


To investigate muscle coactivation patterns during JPS repositioning tasks in ACL-deficient and healthy individuals.


Prospective observational study.


Functional assessment laboratory.


8 men age 25 ± 8 y with isolated ACL rupture and 10 men age 30 ± 4 y with no history of knee injury.


JPS was evaluated by means of an electrogoniometer in a sitting position during either passive or active joint-positioning and -repositioning tasks with a 40° target knee angle.

Main Outcome Measures:

Root mean square (RMS) of the surface electromyogram from the vastus lateralis and biceps femoris muscles was measured during active joint positioning and repositioning.


Healthy participants showed a significant decrease in vastus lateralis RMS (−19%) and an increase in biceps femoris RMS (+26%) during joint repositioning compared with positioning. In contrast, ACL-deficient patients showed no modulation in muscle coactivation between joint positioning and repositioning, although they exhibited significantly lower RMS of the vastus lateralis (injured limb, −28%; uninjured limb, −21%) and higher RMS of the biceps femoris (injured limb, +19%; uninjured limb, +30%) than the healthy participants during joint positioning.


The lack of modulation in muscle coactivation patterns between joint positioning and repositioning in ACL-deficient patients might be attributed to disrupted neural control after the injury-related loss of proprioceptive information. These results should be taken into account in the design of rehabilitation protocols with emphasis on muscle coactivation and JPS.