Michigan Initiative for Anterior Cruciate Ligament Rehabilitation (MiACLR): A Protocol for a Randomized Clinical Trial

Abstract Objective Restoring quadriceps muscle strength following anterior cruciate ligament reconstruction (ACLR) may prevent the posttraumatic osteoarthritis that affects over 50% of knees with ACLR. However, a fundamental gap exists in our understanding of how to maximize muscle strength through rehabilitation. Neurological deficits and muscle atrophy are 2 of the leading mechanisms of muscle weakness after ACLR. High-intensity neuromuscular electrical stimulation (NMES) and eccentric exercise (ECC) have been shown to independently target these mechanisms. If delivered in succession, NMES and then ECC may be able to significantly improve strength recovery. The objectives of this study were to evaluate the ability of NMES combined with ECC to restore quadriceps strength and biomechanical symmetry and maintain cartilage health at 9 and 18 months after ACLR. Methods This study is a randomized, double-blind, placebo-controlled, single-center clinical trial conducted at the University of Michigan. A total of 112 participants between the ages of 14 and 45 years and with an anterior cruciate ligament rupture will be included. Participants will be randomly assigned 1:1 to NMES combined with ECC or NMES placebo combined with ECC placebo. NMES or NMES placebo will be delivered 2 times per week for 8 weeks beginning 10 to 14 days postoperatively and will be directly followed by 8 weeks of ECC or ECC placebo delivered 2 times per week. The co-primary endpoints are change from baseline to 9 months and change from baseline to 18 months after ACLR in isokinetic quadriceps strength symmetry. Secondary outcome measures include isometric quadriceps strength, quadriceps activation, quadriceps muscle morphology (cross-sectional area), knee biomechanics (sagittal plane knee angles and moments), indexes of patient-reported function, and cartilage health (T1ρ and T2 relaxation time mapping on magnetic resonance imaging). Impact The findings from this study might identify an intervention capable of targeting the lingering quadriceps weakness after ACLR and in turn prevent deterioration in cartilage health after ACLR, thereby potentially improving function in this patient population.

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Bridge-Enhanced Anterior Cruciate Ligament Repair Is Not Inferior to Autograft Anterior Cruciate Ligament Reconstruction at 2 Years: Results of a Prospective Randomized Clinical Trial

The American Journal of Sports Medicine ◽

10.1177/0363546520913532 ◽

2020 ◽

Vol 48 (6) ◽

pp. 1305-1315 ◽

Cited By ~ 7

Author(s):

Martha M. Murray ◽

Braden C. Fleming ◽

Gary J. Badger ◽

Christina Freiberger ◽

Rachael Henderson ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Muscle Strength ◽

Cruciate Ligament ◽

Knee Laxity ◽

Acl Injuries ◽

Patient Reported ◽

Subjective Score ◽

Anterior Cruciate ◽

Noninferiority Margin

Background: Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR). Hypothesis: We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, –11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone–patellar tendon–bone]). Outcomes—including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength—were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit. Results: In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, –1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, –0.15 mm [95% CI, –1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure ( P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure. Conclusion: BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified. Registration: NCT02664545 (ClinicalTrials.gov identifier)

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Comparison of Clinical and Dynamic Knee Function in Patients with Anterior Cruciate Ligament Deficiency

The American Journal of Sports Medicine ◽

10.1177/03635465030310012301 ◽

2003 ◽

Vol 31 (1) ◽

pp. 68-74 ◽

Cited By ~ 84

Author(s):

Rohita R. Patel ◽

Debra E. Hurwitz ◽

Charles A. Bush-Joseph ◽

Bernard R. Bach ◽

Thomas P. Andriacchi

Keyword(s):

Anterior Cruciate Ligament ◽

Muscle Strength ◽

Cruciate Ligament ◽

Knee Laxity ◽

Quadriceps Muscle ◽

Stair Climbing ◽

Hamstring Muscle ◽

Flexion Moment ◽

Anterior Cruciate ◽

Normal Strength

Background Whether passive measures of isokinetic muscle strength deficits and knee laxity are related to the dynamic function of the anterior cruciate ligament-deficient knee remains unclear. Hypotheses Arthrometer measurements are not predictive of peak external knee flexion moment (net quadriceps muscle moment), isokinetic quadriceps muscle strength correlates with peak external knee flexion moment (net quadriceps muscle moment), and isokinetic hamstring muscle strength correlates with peak external knee extension moment (net flexor muscle moment). Study Design Cross-sectional study. Methods Gait analysis was used to assess dynamic function during walking, jogging, and stair climbing in 44 subjects with unilateral anterior cruciate ligament deficiency and 44 control subjects. Passive knee laxity and isokinetic quadriceps and hamstring muscle strength were also measured. Results Arthrometer measurements did not correlate with peak external flexion or extension moments in any of the activities tested or with isokinetic quadriceps or hamstring muscle strength. Test subjects also had a significantly reduced peak external flexion moment during all three jogging activities and stair climbing compared with the control subjects and this was correlated with significantly reduced quadriceps muscle strength. Conclusions Absolute knee laxity difference did not correlate with dynamic knee function as assessed by gait analysis and should not be used as a sole predictor for the outcome of treatment. Patients with greater than normal strength in the anterior cruciate ligament-deficient limb performed low- and high-stress activities in a more normal fashion than those with normal or less-than-normal strength.

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Obesity and recovery of muscle strength after anterior cruciate ligament reconstruction in pediatric patients

Journal of Orthopaedic Surgery ◽

10.1177/2309499018806631 ◽

2018 ◽

Vol 26 (3) ◽

pp. 230949901880663 ◽

Cited By ~ 2

Author(s):

R Jay Lee ◽

Adam Margalit ◽

Afam Nduaguba ◽

Melissa A Gunderson ◽

Lawrence Wells

Keyword(s):

Anterior Cruciate Ligament ◽

Muscle Strength ◽

Pediatric Patients ◽

Cruciate Ligament ◽

Peak Torque ◽

Quadriceps Strength ◽

Normal Weight ◽

Muscle Recovery ◽

Concomitant Injuries ◽

Anterior Cruciate

Purpose: To explore factors influencing muscle strength after anterior cruciate ligament (ACL) reconstruction (ACLR) in pediatric patients. We hypothesized that obesity/overweight, autograft hamstring tendon, and concomitant injuries would be associated with slower muscle recovery. Methods: We retrospectively reviewed the records of pediatric ACLR patients during a 3-year period. Muscle recovery was defined as ≥85% of peak torque compared with the contralateral side. We categorized patients as either obese/overweight or normal weight. Statistical analysis was performed using Mann–Whitney U, analysis of variance, and χ2 tests ( α level < 0.05). Results: The study group consisted of 330 patients, of whom 198 (60%) and 231 (70%) met quadriceps and hamstring recovery criteria, respectively, at final testing (mean: 7.0 ± 3.2 months). Patients recovered hamstring and quadriceps strength at a mean of 5.3 ± 2.2 months and 6.1 ± 2.3 months, respectively. Hamstring muscle recovery took significantly longer in obese/overweight patients (mean: 5.7 ± 2.2 months) versus normal-weight patients (mean: 5.1 ± 2.1 months; p = 0.025), but quadriceps recovery did not (obese/overweight mean: 6.5 ± 2.6 months; normal-weight mean: 5.9 ± 2.1 months; p = 0.173). Conclusion: Concomitant injuries and graft type were not associated with length of time to recovery of muscle strength. Obesity/overweight was associated with delay in recovery of hamstring but not quadriceps strength.

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Physiotherapy and Electrical Stimulation Effects on Strength of M. Quadriceps, Knee Range of Motion and Pain in Patients Following Anterior Cruciate Ligament Operation

Reabilitacijos mokslai slauga kineziterapija ergoterapija ◽

10.33607/rmske.v1i16.740 ◽

2019 ◽

Vol 1 (16) ◽

Author(s):

Justina Marčiulionytė ◽

Justinas Škikas ◽

Saulė Sipavičienė

Keyword(s):

Anterior Cruciate Ligament ◽

Electrical Stimulation ◽

Muscle Strength ◽

Range Of Motion ◽

Cruciate Ligament ◽

Quadriceps Muscle ◽

Control Group ◽

Study Group ◽

Quadriceps Muscle Strength ◽

Anterior Cruciate

Background. Research aim was to analyze the quadriceps muscle strength recovery after anterior cruciate ligament reconstruction using electrical stimulation and physical therapy. Methods. There were two randomly selected groups, with eight people in each group. The selection criteria were that the subjects had to have anterior cruciate ligament operation six weeks prior and were very active physically. One group was for research (study group), the other one for reference (control group). The study group had electrical stimulation combined with physical therapy exercises two times a week, for 45 minutes. The control group had exercises to strengthen the quadriceps muscle also two times a week, for 45 minutes. Both groups were tested before and after the research. The things evaluated during the test were – visual pain scale (VAS) scores, quadriceps muscle strength during extension and ﬂexion using (R. Lovett) scoring system and goniometry showing degrees of extension and ﬂexion. Results. Comparing both study and control groups, there was statistically signifcant improvement (p < 0.05), however the study group recovered faster and had statistically greater benefts. Conclusions. After 6 weeks of physiotherapy, the range of motion, quadriceps muscle strength increased and pain decreased in the operated leg. 1. After 6 weeks of physiotherapy and electrical stimulation, the range of motion, quadriceps muscle strength increased and pain decreased in the operated leg. 2. After 6 weeks of physiotherapy and electrical stimulation, the range of motion, quadriceps muscle strength, pain in the operated leg changed more in the study group than in subjects who received only physical therapy.Keywords: anterior cruciate ligament, electrical stimulation, quadriceps muscle, ligament reconstruction, muscle strength.

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The Effectiveness of Nonoperative Treatment for Anterior Cruciate Ligament Rupture on Patient-Reported Outcomes and Muscular Strength: A Critically Appraised Topic

Journal of Sport Rehabilitation ◽

10.1123/jsr.2019-0131 ◽

2020 ◽

Vol 29 (7) ◽

pp. 1032-1037

Author(s):

Emily R. Hunt ◽

Cassandra N. Parise ◽

Timothy A. Butterfield

Keyword(s):

Anterior Cruciate Ligament ◽

Cruciate Ligament ◽

Quadriceps Strength ◽

Nonoperative Treatment ◽

Long Term Results ◽

Bottom Line ◽

Hop Tests ◽

Patient Reported ◽

Anterior Cruciate

Clinical Scenario: Anterior cruciate ligament (ACL) ruptures are one of the most common injuries in young athletic populations. The leading treatment for these injuries is ACL reconstruction (ACL-r); however, nonoperative treatments are also utilized. Following ACL-r, patients experience prolonged muscle weakness and atrophy of the quadriceps muscle group, regardless of rehabilitation. Nonoperative treatment plans following ACL injury exist, but their outcomes are less familiar, in spite of providing insight as a nonsurgical “control” for postsurgical rehabilitation outcomes. Therefore, the purpose of this critically appraised topic was to evaluate quadriceps strength and function following nonoperative ACL rehabilitation using objective and subjective measures including isokinetic dynamometry, the single-leg hop test, and the International Knee Documentation Committee (IKDC) subjective knee form. Focused Clinical Question: What are the effects of nonoperative treatment on peak isokinetic knee-extensor torque, the single-leg hop tests, and the IKDC in patients who have sustained an ACL rupture? Summary of Key Findings: Patients who underwent nonsurgical ACL treatment produced limb symmetry index, with the side-to-side torque difference expressed as a percentage, and values at or above 90% for all 4 single-leg hop tests and strength tests similar to ACL-r patients. All studies showed individuals had higher IKDC scores at baseline collection when compared with patients who underwent ACL-r but showed lower IKDC scores at long-term follow-up compared with ACL-r patients. Clinical Bottom Line: Nonoperative treatments of ACL injuries yield similar long-term results in quadriceps strength as ACL-r. Due to the quality of evidence and the absence of randomized controlled trials on this topic, these outcomes should be considered with caution. Strength of Recommendation: The Oxford Centre for Evidence-Based Medicine taxonomy recommends a grade of B for level 2 evidence with consistent findings.

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Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial

Physical Therapy ◽

10.1093/ptj/pzz062 ◽

2019 ◽

Vol 99 (8) ◽

pp. 1010-1019 ◽

Cited By ~ 2

Author(s):

Lauren N Erickson ◽

Kathryn C Hickey Lucas ◽

Kylie A Davis ◽

Cale A Jacobs ◽

Katherine L Thompson ◽

...

Keyword(s):

Blood Flow ◽

Anterior Cruciate Ligament ◽

Knee Flexion ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Quadriceps Muscle ◽

Quadriceps Strength ◽

Knee Biomechanics ◽

Flow Restriction ◽

Anterior Cruciate

Abstract Background Despite best practice, quadriceps strength deficits often persist for years after anterior cruciate ligament reconstruction. Blood flow restriction training (BFRT) is a possible new intervention that applies a pressurized cuff to the proximal thigh that partially occludes blood flow as the patient exercises, which enables patients to train at reduced loads. This training is believed to result in the same benefits as if the patients were training under high loads. Objective The objective is to evaluate the effect of BFRT on quadriceps strength and knee biomechanics and to identify the potential mechanism(s) of action of BFRT at the cellular and morphological levels of the quadriceps. Design This will be a randomized, double-blind, placebo-controlled clinical trial. Setting The study will take place at the University of Kentucky and University of Texas Medical Branch. Participants Sixty participants between the ages of 15 to 40 years with an ACL tear will be included. Intervention Participants will be randomly assigned to (1) physical therapy plus active BFRT (BFRT group) or (2) physical therapy plus placebo BFRT (standard of care group). Presurgical BFRT will involve sessions 3 times per week for 4 weeks, and postsurgical BFRT will involve sessions 3 times per week for 4 to 5 months. Measurements The primary outcome measure was quadriceps strength (peak quadriceps torque, rate of torque development). Secondary outcome measures included knee biomechanics (knee extensor moment, knee flexion excursion, knee flexion angle), quadriceps muscle morphology (physiological cross-sectional area, fibrosis), and quadriceps muscle physiology (muscle fiber type, muscle fiber size, muscle pennation angle, satellite cell proliferation, fibrogenic/adipogenic progenitor cells, extracellular matrix composition). Limitations Therapists will not be blinded. Conclusions The results of this study may contribute to an improved targeted treatment for the protracted quadriceps strength loss associated with anterior cruciate ligament injury and reconstruction.

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Factors That Predict Sagittal Plane Knee Biomechanical Symmetry After Anterior Cruciate Ligament Reconstruction: A Decision Tree Analysis

Sports Health A Multidisciplinary Approach ◽

10.1177/19417381211004932 ◽

2021 ◽

pp. 194173812110049

Author(s):

Riann M. Palmieri-Smith ◽

Michael T. Curran ◽

Steven A. Garcia ◽

Chandramouli Krishnan

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Sagittal Plane ◽

Cruciate Ligament ◽

Quadriceps Strength ◽

Return To Play ◽

Knee Biomechanics ◽

Level Of Evidence ◽

Patient Reported ◽

Anterior Cruciate

Background: Biomechanical knee asymmetry is commonly present after anterior cruciate ligament (ACL) reconstruction. Factors that could assist in identification of asymmetrical biomechanics after ACL reconstruction could help clinicians in making return-to-play decisions. The purpose of this study is to determine factors that may contribute to knee biomechanical asymmetry present after ACL reconstruction. Hypothesis: We hypothesized that quadriceps strength and activation and patient-reported function would allow for identification of patients with symmetrical knee biomechanics. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: Thirty-one subjects (18 women; time since ACL reconstruction = 284.4 ± 53.6 days) who underwent ACL reconstruction and were to return to activity were recruited. Participants completed bilateral assessments of isokinetic quadriceps strength, quadriceps activation using the superimposed burst technique, and biomechanical function testing during a single-leg forward hop. The International Knee Documentation Committee (IKDC) subjective knee form was also completed. Symmetry values were calculated for each variable. Decision trees were utilized to determine which input factors (quadriceps strength symmetry, quadriceps activation symmetry, IKDC score, age, sex, height, mass, graft type) were able to identify participants who had symmetrical knee flexion angles (KFAs) and extension moments. Angles and moments were considered symmetrical if symmetry values were ≥90%. Results: Quadriceps strength and activation symmetry were able to predict whether a patient landed with symmetrical or asymmetrical KFAs, with thresholds of 77.2% strength symmetry and 91.3% activation symmetry being established. Patient-reported function and quadriceps strength were factors that allowed for classification of participants with symmetrical/asymmetrical knee extension moments, with thresholds of 89.1 for the IKDC and 80.0% for quadriceps strength symmetry. Conclusions: Quadriceps strength contributed to both models and appears to be a critical factor for achieving symmetrical knee biomechanics. High patient-reported function and quadriceps activation are also important for restoring knee biomechanical symmetry after ACL reconstruction. Clinical Relevance: Quadriceps strength and activation and patient-reported function may be able to assist clinicians in identifying ACL patients with symmetrical/asymmetrical knee biomechanics.

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Supervised Rehabilitation May Lead to Better Outcome than Home-Based Rehabilitation Up to 1 Year after Anterior Cruciate Ligament Reconstruction

Medicina ◽

10.3390/medicina57010019 ◽

2020 ◽

Vol 57 (1) ◽

pp. 19

Author(s):

Hye Chang Rhim ◽

Jin Hyuck Lee ◽

Seo Jun Lee ◽

Jin Sung Jeon ◽

Geun Kim ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Muscle Strength ◽

Anterior Cruciate Ligament Reconstruction ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Neuromuscular Control ◽

Cruciate Ligament Reconstruction ◽

Home Based ◽

Patient Reported ◽

Anterior Cruciate

Background and objectives: Previous studies consistently found no significant difference between supervised and home-based rehabilitation after anterior cruciate ligament reconstruction (ACLR). However, the function of the nonoperative knee, hamstring strength at deep flexion, and neuromuscular control have been overlooked. This prospective observational study was performed to investigate the outcomes after ACLR in operative and nonoperative knees between supervised and home-based rehabilitations. Materials and Methods: After surgery, instructional videos demonstrating the rehabilitation process and exercises were provided for the home-based rehabilitation group. The supervised rehabilitation group visited our sports medicine center and physical therapists followed up all patients during the entire duration of the study. Isokinetic muscle strength and neuromuscular control (acceleration time (AT) and overall stability index (OSI)) of both operative and nonoperative knees, as well as patient-reported knee function (Lysholm score), were measured and compared between the two groups 6 months and 1 year postoperatively. Results: The supervised rehabilitation group showed higher muscle strength of hamstring and quadriceps in nonoperative knees at 6 months (hamstring, p = 0.033; quadriceps, p = 0.045) and higher hamstring strength in operative and nonoperative knees at 1 year (operative knees, p = 0.035; nonoperative knees, p = 0.010) than the home-based rehabilitation group. At 6 months and 1 year, OSIs in operative and nonoperative knees were significantly better in the supervised rehabilitation group than in the home-based rehabilitation group (operative knees, p < 0.001, p < 0.001; nonoperative knees, p < 0.001, p < 0.001, at 6 months and 1 year, respectively). At 1 year, the supervised rehabilitation group also demonstrated faster AT of the hamstrings (operative knees, p = 0.016; nonoperative knees, p = 0.036). Lysholm scores gradually improved in both groups over 1 year; however, the supervised rehabilitation group showed higher scores at 1 year (87.3 ± 5.8 vs. 75.6 ± 15.1, p = 0.016). Conclusions: This study demonstrated that supervised rehabilitation may offer additional benefits in improving muscle strength, neuromuscular control, and patient-reported knee function compared with home-based rehabilitation up to 1 year after ACLR.

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