Strength Asymmetry and Landing Mechanics at Return to Sport after Anterior Cruciate Ligament Reconstruction

Abstract

Purpose: Evidence-based quadriceps femoris muscle (QF) strength guidelines for return to sport after anterior cruciate ligament (ACL) reconstruction are lacking. This study investigated the effect of QF strength asymmetry on knee landing biomechanics at the time of return to sport after ACL reconstruction.

Methods: Seventy-seven individuals (17.4 yr) at the time of return to sport after primary ACL reconstruction (ACLR group) and 47 uninjured control individuals (17.0 yr; CTRL group) participated. QF strength was assessed and quadriceps index was calculated (QI = [involved strength / uninvolved strength] × 100%). The ACLR group was subdivided based on QI: high quadriceps (HQ, QI ≥ 90%) and low quadriceps (LQ, QI < 85%). Knee kinematic and kinetic variables were collected during a drop vertical jump maneuver. Limb symmetry during landing and discrete variables were compared among the groups using multivariate analysis of variance and linear regression analyses.

Results: The LQ group demonstrated worse asymmetry in all kinetic and ground reaction force variables compared to the HQ and CTRL groups, including reduced involved limb peak knee external flexion moments (P < 0.001), reduced involved limb (P = 0.003) and increased uninvolved limb (P = 0.005) peak vertical ground reaction forces and higher uninvolved limb peak loading rates (P < 0.004). There were no differences in the landing patterns between the HQ and CTRL groups on any variable (P > 0.05). In the ACLR group, QF strength estimated limb symmetry during landing after controlling for graft type, meniscus injury, knee pain, and symptoms.

Conclusions: At the time of return to sport, individuals after ACL reconstruction with weaker QF demonstrate altered landing patterns. Conversely, those with nearly symmetrical QF strength demonstrate landing patterns similar to uninjured individuals. Consideration of an objective QF strength measure may aid clinical decision making to optimize sports participation after ACL reconstruction.

FIGURE 1

Limb symmetry for peak kinematic and kinetic variables of interest during landing between the strength groups (*LQ significantly less than HQ, †LQ significantly less than CTRL) with 100 indicating perfect symmetry between the involved/test and uninvolved/non-test limbs. CTRL, control group; HQ, High Quadriceps group; LQ, Low Quadriceps group; Ang, angle; Flex Mom, external flexion moment; vGRF Land, peak vertical ground reaction force.