No Relationship Between Preoperative and Early Postoperative Strength After ACL Reconstruction

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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Fracture of the Patella During Rehabilitation of the Knee Extensor Muscles Following Reconstruction of the Anterior Cruciate Ligament

Clinical Journal of Sport Medicine ◽

10.1097/00042752-199304000-00008 ◽

1993 ◽

Vol 3 (2) ◽

pp. 118-122 ◽

Cited By ~ 4

Author(s):

Côme S. Bouchard ◽

Germain Thériault ◽

Janik M. Gauthier ◽

François Morin ◽

Jean-Aimé Simoneau

Keyword(s):

Anterior Cruciate Ligament ◽

Cruciate Ligament ◽

Knee Extensor ◽

Extensor Muscles ◽

Anterior Cruciate ◽

Knee Extensor Muscles

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Arthroscopic anterior cruciate ligament reconstruction with semitendinosus graft versus peroneus longus tendon graft

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20200735 ◽

2020 ◽

Vol 6 (2) ◽

pp. 386

Author(s):

Pudari Manoj Kumar ◽

Ishan Shevte ◽

Mukesh Phalak ◽

Abhishek Nair ◽

Parth .

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Tendon Graft ◽

Collateral Ligament ◽

Peroneus Longus Tendon ◽

Longus Tendon ◽

Peroneus Longus ◽

Anterior Cruciate ◽

Tendon Autograft

Background: Arthroscopic anterior cruciate ligament (ACL) reconstruction can be performed using autograft from various sources namely, bone patellar tendon graft, hamstring tendons (semitendinosus, gracilis) or peroneus longus tendon.Methods: A prospective study of 30 patients who underwent arthroscopic ACL reconstruction using quadrupled semitendinosus tendon autograft and peroneus longus tendon autograft during the study period.Results: Statistically, there is very little comparable difference between semitendinosus and peroneus longus when used for arthroscopic ACL reconstruction. However, peroneus longus tendon shows superior results when used in patients with grade 3 medial collateral ligament (MCL) injury combined with ACL injury.Conclusions: Our study brings forth the superior efficacy and quality of the double stranded peroneus longus tendon especially in cases associated with complicated injuries involving the medial collateral ligament with a follow up date of about 2 years and as a healthy supplement to other choices of autografts and revision cases.

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Blood Flow Restriction Training Does Not Improve Quadriceps Strength After Anterior Cruciate Ligament Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00293 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0029

Author(s):

Michael Curran ◽

Asheesh Bedi ◽

Christopher Mendias ◽

Edward M. Wojtys ◽

Megan Kujawa ◽

...

Keyword(s):

Blood Flow ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Quadriceps Strength ◽

Blood Flow Restriction ◽

Effect Sizes ◽

Leg Press ◽

Symmetry Index ◽

Flow Restriction ◽

Anterior Cruciate

Objectives: Blood flow restriction training (BFRT) involves obstruction of venous outflow of working muscles during exercise and may lead to more substantial recovery of quadriceps strength after anterior cruciate ligament (ACL) reconstruction. The purpose of this study is to examine the effects of BFRT in ACL reconstruction patients before and after exposure to BFRT. Methods: This study was a randomized controlled trial in which 36 patients who had torn their ACL and were scheduled to undergo ACL reconstructive surgery (ACLR) with an autograft were randomized to receive exercise with BFRT (N=18) or exercise without BFRT (N=18). Participants in both groups performed the same exercise, but either did or did not have blood flow restricted. The exercise component of the intervention consisted of all subjects performing a single-leg isokinetic leg press, at an intensity of 70% of the subjects’ one-repetition maximum, for four sets of ten repetitions two times per week for 8 weeks beginning at 8 weeks post-operatively. Patients randomized to the BFRT group performed the leg-press exercise with a blood flow restriction cuff applied to the thigh and set to a limb occlusion pressure of 80 percent. All participants were concurrently undergoing standard ACL rehabilitation at the same physical therapy clinic. Bilateral isometric (recorded at a knee angle of 90°) and isokinetic (60°/second) quadriceps strength were recorded using a Biodex dynamometer (System 4, Shirley, NY) prior to ACLR and after the conclusion of the 8-week intervention. Peak isometric and isokinetic quadriceps strength were utilized to generate isometric and isokinetic quadriceps symmetry indices ((ACLR limb strength/Healthy limb strength) x100). Change from baseline symmetry scores were then generated using the following equation: (post-intervention symmetry - pre-intervention symmetry)/pre-intervention symmetry in order to account for possible differences in strength between groups prior to intervention delivery. Change from baseline isometric and isokinetic quadriceps symmetry scores were then compared between groups (exercise with BFRT, exercise without BFRT) using one-way analysis of variance tests with an a priori α set to P≤ 0.05. Effect sizes (Cohen’s d) and 95% confidence intervals were also computed. Results: No significant differences were found for change from baseline isokinetic quadriceps symmetry index (P=0.39, BFRT mean=-0.05, Control mean=-0.19) or change from baseline isometric quadriceps symmetry index (P=0.62, BFRT mean=-0.04, control mean=-0.10). The effect sizes for isokinetic quadriceps symmetry index (d=0.28, 95% CI= -0.37, 0.93) and isometric quadriceps symmetry (d=0.16, 95% CI= -0.49, 0.80) were small with confidence intervals that crossed zero. Conclusion: An 8-week blood flow resistance training + exercise intervention did not increase quadriceps muscle strength in patients who had undergone ACL reconstruction. Based on our findings, application of blood flow restriction training in ACL reconstruction patients to improve quadriceps strength may not be warranted. Future studies may benefit from a longer follow-up and larger sample size.

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Is Pre-operative Quadriceps Strength a Predictive Factor for the Outcomes of Anterior Cruciate Ligament Reconstructions

International Journal of Sports Medicine ◽

10.1055/a-1144-3111 ◽

2020 ◽

Vol 41 (13) ◽

pp. 912-920

Author(s):

Jihong Qiu ◽

Xin He ◽

Sai-Chuen Fu ◽

Michael Tim-Yun Ong ◽

Hio Teng Leong ◽

...

Keyword(s):

Acl Reconstruction ◽

Predictive Value ◽

Cruciate Ligament ◽

Positive Association ◽

Quadriceps Strength ◽

Treatment Protocols ◽

Strength Assessment ◽

Operative Outcomes ◽

Anterior Cruciate

AbstractPersistent quadriceps weakness prevents patients from returning to sports after ACL reconstruction. Pre-operative quadriceps strength was indicated as an important factor for the outcomes of ACL reconstruction. However, the existing evidence is controversial. Therefore, this systematic review was conducted to summarize and evaluate the relationship between pre-operative quadriceps strength and the outcomes following ACL reconstruction, and to summarize the predictive value of pre-operative quadriceps strength for satisfactory post-operative outcomes. Pubmed, WOS, Embase, CINAHL and SportDiscus were searched to identify eligible studies according to PRISMA guidelines. Relevant data was extracted regarding quadriceps strength assessment methods, pre-operative quadriceps strength, participants treatment protocols, post-operative outcomes, follow-up time points and the relevant results of each individual study. Twelve cohort studies (Coleman methodology score: 62±10.4; from 44–78) with 1773 participants included. Follow-up period ranged from 3 months to 2 years. Moderate evidence supports the positive association between pre-operative quadriceps strength and post-operative quadriceps strength; weak evidence supports the positive association between pre-operative quadriceps strength and post-operative functional outcomes. By now, there is no consensus on the predictive value of pre-operative quadriceps strength for achieving satisfactory quadriceps strength after ACLR. To conclude, pre-operative quadriceps strength should be taken into consideration when predict patient recovery of ACLR.

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Conditioning Brain Responses to Improve Quadriceps Function in an Individual With Anterior Cruciate Ligament Reconstruction

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738119835163 ◽

2019 ◽

Vol 11 (4) ◽

pp. 306-315 ◽

Cited By ~ 4

Author(s):

Chandramouli Krishnan ◽

Edward P. Washabaugh ◽

Aviroop Dutt-Mazumder ◽

Scott R. Brown ◽

Edward M. Wojtys ◽

...

Keyword(s):

Acl Reconstruction ◽

Operant Conditioning ◽

Muscle Activation ◽

Cruciate Ligament ◽

Knee Extensor ◽

Quadriceps Muscle ◽

Corticospinal Excitability ◽

Knee Extensor Strength ◽

Anterior Cruciate ◽

Quadriceps Function

Background: Persistent quadriceps weakness and activation failure are common in individuals with anterior cruciate ligament (ACL) reconstruction. A growing body of evidence indicates that this chronic quadriceps dysfunction could be partly mediated due to reduced corticospinal excitability. However, current rehabilitation approaches do not directly target corticospinal deficits, which may be critical for restoring optimal clinical outcomes after the surgery. This case study tested the feasibility of operant conditioning of torque responses evoked by transcranial magnetic stimulation (TMS) to improve quadriceps function after ACL reconstruction. Hypothesis: Operant conditioning of motor evoked torque responses would improve quadriceps strength, voluntary activation, and corticospinal excitability. Study Design: Case study and research report. Level of Evidence: Level 5. Methods: A 24-year-old male with an ACL reconstruction (6 months postsurgery) trained for 20 sessions (2-3 times per week for 8 weeks) to increase his TMS-induced motor evoked torque response (MEP torque) of the quadriceps muscles using operant conditioning principles. Knee extensor strength, voluntary quadriceps muscle activation, and quadriceps corticospinal excitability were evaluated at 3 time points: preintervention (pre), 4 weeks (mid), and immediately after the intervention (post). Results: The participant was able to successfully condition (ie, increase) the quadriceps MEP torque after 1 training session, and the conditioned MEP torque gradually increased over the course of 20 training sessions to reach about 500% of the initial value at the end of training. The participant’s control MEP torque values and corticospinal excitability, which were measured outside of the conditioning paradigm, also increased with training. These changes were paralleled by improvements in knee extensor strength and voluntary quadriceps muscle activation. Conclusion: This study shows that operant conditioning of MEP torque is a feasible approach to improving quadriceps corticospinal excitability and quadriceps function after ACL reconstruction and encourages further testing in a larger cohort of ACL-reconstructed individuals. Clinical Relevance: Operant conditioning may serve as a potential therapeutic adjuvant for ACL rehabilitation.

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Current Evidence in Anterior Cruciate Ligament Rehabilitation: Neuromuscular Electrical Stimulation Combined With a Strengthening Program: A Critically Appraised Topic

International Journal of Athletic Therapy & Training ◽

10.1123/ijatt.2016-0107 ◽

2017 ◽

Vol 22 (6) ◽

pp. 5-11

Author(s):

Michael E. Lynch ◽

Christine A. Lauber

Keyword(s):

Anterior Cruciate Ligament ◽

Electrical Stimulation ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Neuromuscular Electrical Stimulation ◽

Quadriceps Strength ◽

Sufficient Evidence ◽

Clinical Question ◽

Bottom Line ◽

Anterior Cruciate

Clinical Question:Is it beneficial to add neuromuscular electrical stimulation (NMES) to a strengthening program after anterior cruciate ligament (ACL) reconstruction surgery?Clinical Bottom Line:There is sufficient evidence to support the inclusion of NMES in a rehabilitation strengthening program post ACL reconstruction. All three included studies reported significant quadriceps strength gains (p < .05) in favor of the group that completed both NMES and strengthening exercises compared with a strength-only group. Two studies initiated NMES within 4 days of surgery. One study found significant quadriceps strength increases when NMES was implemented 6 months after surgery.

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Higher Rate of Patellofemoral Problems After Anterior Cruciate Ligament Reconstruction using Hamstring Autograft

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2021.6626 ◽

2021 ◽

Vol 9 (B) ◽

pp. 811-815

Author(s):

Krisna Yuarno Phatama ◽

Romy Darmawansa ◽

I Gusti Ngurah Arga Aldrian Oktafandi ◽

Felix Cendikiawan ◽

Alva Pribadi ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Single Bundle ◽

Hamstring Autograft ◽

Peroneus Longus Tendon ◽

Peroneus Longus ◽

Kujala Score ◽

Anterior Cruciate ◽

Tendon Autograft

Background: Patellofemoral problems are not uncommon among post-anterior cruciate ligament (ACL) reconstruction patients. Hamstring autograft harvesting-related factor is one of the suspected causes. A lack of tibiofemoral internal rotation force due to strength deficit causes the patella tends to shift laterally. Purposes: Peroneus longus tendon has been proposed as an alternative graft source due to its adequate tensile strength and minimal donor site morbidity to the knee biomechanics, including the patellofemoral joint. This tendon does not cross the knee joint and thus does not affect patellofemoral alignment and biomechanics. This study aims to compare patellofemoral problems between hamstring and peroneus longus autograft harvested-patients following ACL reconstruction. Material and methods: Thirty-one subjects who underwent primary single-bundle ACL reconstruction between September 2018 and September 2019 and met the inclusion criteria were grouped into the hamstring group (n=16) and peroneus longus group (n=15). Both groups were evaluated retrospectively. The follow-up assessment was conducted on the phase II rehabilitation program. The assessed variables were pain, crepitus, and the Indonesian-validated Kujala score. Results: No significant differences in pain and crepitus were found between both groups. There were significant differences in the Kujala score between both groups (P < .001). The peroneus longus group reported an averagely higher score than the hamstring group. Conclusion: Single bundle ACL reconstruction using peroneus longus tendon autograft produces less patellofemoral symptoms and functional limitation than using hamstring tendon autograft.

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Results of Anterior Cruciate Ligament Injuries by Arthroscopic Reconstruction Using Semitendinosus Tendon

Journal of Pharmaceutical Research International ◽

10.9734/jpri/2021/v33i28b31548 ◽

2021 ◽

pp. 142-148

Author(s):

Nuresh Kumar Valecha ◽

Niaz Hussain Keerio ◽

Masood Ahmed Qureshi ◽

Syed Sajid Hussain ◽

Hassan Amir us Saqlain ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Semitendinosus Tendon ◽

Reconstruction Technique ◽

Ligament Injuries ◽

Arthroscopic Reconstruction ◽

Anterior Cruciate Ligament Injuries ◽

Anterior Cruciate ◽

Tendon Autograft

Objectives: This study was designed to evaluate the surgical management of anterior cruciate ligament injuries by arthroscopic reconstruction using semitendinosus grafts. Methodolgy: This study was conducted by Dibba Hospital Fujairah, United Arab Emirates from March 2017- to March 2020. A total of 40 patients were selected for this research. In our study, we used arthroscopy assisted ACL reconstruction technique with single bundle quadrupled semitendinosus tendon autograft. This autograft was inserted from the ipsilateral limb with the help of endobutton femoral side of graft was fixed and with bioabsorbable screw tibial side of graft was stabilized. A single surgeon performed all the surgeries. Results: In our observations, we reported that the majority of the patients had exposure of ACL injury in their middle adult age (32-38 years old) due to high engagement in physical activities (67.8%) like biking, playing sports and many others. The ratio of right knee injury site was comparatively high (53.5%) than the left one (46.4%). Conclusion: From the results, we concluded that the younger age group is more prone to anterior Cruciate ligament injury. ACL reconstruction with Semitendinosus tendon autograft helps in maintaining knee movement and assist in early knee stability.

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Single-Leg Squat Performance and Its Relationship to Extensor Mechanism Strength After Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546519878432 ◽

2019 ◽

Vol 47 (14) ◽

pp. 3423-3428 ◽

Cited By ~ 4

Author(s):

Lachlan M. Batty ◽

Julian A. Feller ◽

Taylor Hartwig ◽

Brian M. Devitt ◽

Kate E. Webster

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Knee Extensor ◽

Extensor Mechanism ◽

Flexion Angle ◽

Maximum Flexion ◽

Knee Extensor Strength ◽

Maximum Flexion Angle ◽

Anterior Cruciate ◽

Primary Acl Reconstruction

Background: Performance in strength and functional testing is important when considering return to sport after anterior cruciate ligament (ACL) reconstruction. Both knee extensor strength and the single-leg squat (SLS) have been used in this context. Purpose: To evaluate the relationship between knee extensor strength and SLS performance after primary ACL reconstruction. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: A prospective cohort of 100 patients was assessed 6 and 12 months after primary ACL reconstruction with a hamstring tendon autograft. Knee extensor peak torque was measured. Three sequential SLSs were performed, and the maximum flexion angle identified from frame-by-frame video analysis was used as the measure of squat performance. A limb symmetry index (LSI) was calculated and satisfactory performance defined as ≥90%. Results: Extensor mechanism strength deficits were seen in 75% of patients at 6 months and 57% at 12 months postoperatively. Mean extensor mechanism strength showed a large improvement between 6 and 12 months (123.6 vs 147.8 N·m, respectively; P < .001; Cohen d = 1.10), and while there was also a statistically significant improvement in the mean maximum flexion angle, the change was small (66.1° vs 68.1°, respectively; P = .011; Cohen d = 0.26). There was a weak positive correlation between knee extensor strength and the SLS maximum flexion angle at 6 months ( r = 0.342; P < .001) and 12 months ( r = 0.245; P = .014). An SLS LSI <90% was 80% specific and 35% sensitive for extensor mechanism weakness at 6 months and 79% specific and 18% sensitive at 12 months. Conclusion: Extensor mechanism strength deficits are common after ACL reconstruction but reduce between 6 and 12 months. The SLS maximum flexion angle has a weak linear relationship to knee extensor strength. SLS performance has high specificity but low sensitivity in identifying extensor mechanism strength deficits. The SLS maximum flexion angle is therefore a suboptimal surrogate test to identify extensor mechanism strength deficits as diagnosed by isokinetic dynamometric testing. However, unsatisfactory SLS performance indicates a very high chance of underlying extensor mechanism weakness.

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