An anterior cruciate ligament injury does not affect the neuromuscular function of the non-injured leg except for dynamic balance and voluntary quadriceps activation

Abstract

Purpose: The function of the anterior cruciate ligament (ACL) patients' non-injured leg is relevant in light of the high incidence of secondary ACL injuries on the contralateral side. However, the non-injured leg's function has only been examined for a selected number of neuromuscular outcomes and often without appropriate control groups. We measured a broad array of neuromuscular functions between legs of ACL patients and compared outcomes to age, sex, and physical activity matched controls.

Methods: Thirty-two ACL-deficient patients (208 ± 145 days post-injury) and active and less-active controls (N = 20 each) participated in the study. We measured single- and multi-joint neuromuscular function in both legs in each group and expressed the overall neuromuscular function in each leg by calculating a mean z-score across all neuromuscular measures. A group by leg MANOVA and ANOVA were performed to examine group and leg differences for the selected outcomes.

Results: After an ACL injury, duration (-4.3 h/week) and level (Tegner activity score of -3.9) of sports activity decreased and was comparable to less-active controls. ACL patients showed bilateral impairments in the star excursion balance test compared to both control groups (P ≤ 0.004) and for central activation ratio compared to active controls (P ≤ 0.002). There were between-leg differences within each group for maximal quadriceps and hamstring strength, voluntary quadriceps activation, star excursion balance test performance, and single-leg hop distance (all P < 0.05), but there were no significant differences in quadriceps force accuracy and variability, knee joint proprioception, and static balance. Overall neuromuscular function (mean z-score) did not differ between groups, but ACL patients' non-injured leg displayed better neuromuscular function than the injured leg (P < 0.05).

Conclusions: Except for poorer dynamic balance and reduced quadriceps activation, ACL patients had no bilateral neuromuscular deficits despite reductions in physical activity after injury. Therapists can use the non-injured leg as a reference to assess the injured leg's function for tasks measured in the present study, excluding dynamic balance and quadriceps activation. Rehabilitation after an ACL injury should be mainly focused on the injured leg.

Level of evidence: III.

Keywords: ACL deficient; Bilateral impairment; Force accuracy; Force variability; Maximal voluntary force; Postural balance; Proprioception; Twitch interpolation.

Fig. 1

Voluntary quadriceps activation determined for a single subject using linear regression equation (y = −0.56x + 85.11; R = −0.96). The open circles represent the four data points used for calculating the linear regression equation. Intersection point with the x-axis is the estimated maximal torque (151.3 Nm, filled circle). Intersection point with the y-axis using the maximal quadriceps torque is the estimated quadriceps activation (−25.9 %, filled triangle). Note the estimated maximal torque underestimates the produced maximal torque (197.3 Nm, filled square)

Fig. 2

Overall index of neuromuscular function expressed as the mean z-score calculated over all neuromuscular measures. A z-score of zero reflects the mean neuromuscular function pooled across all six legs. ^†Between-leg difference within each group (P < 0.05). Note no bilateral impairments were observed