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Bühl L, Müller S, Nüesch C, Boyer KA, Casto E, Mündermann A, Egloff C. Ambulatory knee biomechanics and muscle activity 2 years after ACL surgery: InternalBrace TM-augmented ACL repair versus ACL reconstruction versus healthy controls. BMC Musculoskelet Disord 2023; 24:785. [PMID: 37794432 PMCID: PMC10548591 DOI: 10.1186/s12891-023-06916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Little is known about knee mechanics and muscle control after augmented ACL repair. Our aim was to compare knee biomechanics and leg muscle activity during walking between the legs of patients 2 years after InternalBraceTM-augmented anterior cruciate ligament repair (ACL-IB) and between patients after ACL-IB and ACL reconstruction (ACL-R), and controls. METHODS Twenty-nine ACL-IB, 27 sex- and age-matched ACL-R (hamstring tendon autograft) and 29 matched controls completed an instrumented gait analysis. Knee joint angles, moments, power, and leg muscle activity were compared between the involved and uninvolved leg in ACL-IB (paired t-tests), and between the involved legs in ACL patients and the non-dominant leg in controls (analysis of variance and posthoc Bonferroni tests) using statistical parametric mapping (SPM, P < 0.05). Means and 95% confidence intervals (CI) of differences in discrete parameters (DP; i.e., maximum/minimum) were calculated. RESULTS Significant differences were observed in ACL-IB only in minimum knee flexion angle (DP: 2.4°, CI [-4.4;-0.5]; involved > uninvolved) and maximum knee flexion moment during stance (-0.07Nm/kg, CI [-0.13;-0.00]; involved < uninvolved), and differences between ACL-IB and ACL-R only in maximum knee flexion during swing (DP: 3.6°, CI [0.5;7.0]; ACL-IB > ACL-R). Compared to controls, ACL-IB (SPM: 0-3%GC, P = 0.015; 98-100%, P = 0.016; DP: -6.3 mm, CI [-11.7;-0.8]) and ACL-R (DP: -6.0 mm, CI [-11.4;-0.2]) had lower (maximum) anterior tibia position around heel strike. ACL-R also had lower maximum knee extension moment (DP: -0.13Nm/kg, CI [-0.23;-0.02]) and internal knee rotation moment (SPM: 34-41%GC, P < 0.001; DP: -0.03Nm/kg, CI [-0.06;-0.00]) during stance, and greater maximum semitendinosus activity before heel strike (DP: 11.2%maximum voluntary contraction, CI [0.1;21.3]) than controls. CONCLUSION Our results suggest comparable ambulatory knee function 2 years after ACL-IB and ACL-R, with ACL-IB showing only small differences between legs. However, the differences between both ACL groups and controls suggest that function in the involved leg is not fully recovered and that ACL tear is not only a mechanical disruption but also affects the sensorimotor integrity, which may not be restored after surgery. The trend toward fewer abnormalities in knee moments and semitendinosus muscle function during walking after ACL-IB warrants further investigation and may underscore the importance of preserving the hamstring muscles as ACL agonists. LEVEL OF EVIDENCE Level III, case-control study. TRIAL REGISTRATION clinicaltrials.gov, NCT04429165 (12/06/2020).
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Affiliation(s)
- Linda Bühl
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland.
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland.
| | - Sebastian Müller
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
| | - Corina Nüesch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Katherine A Boyer
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA, 01003, USA
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Erica Casto
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA, 01003, USA
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Christian Egloff
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
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Rhodes D, Jeffrey J, Maden-Wilkinson J, Reedy A, Morehead E, Kiely J, Birdsall D, Carling C, Alexander J. The relationship between eccentric hamstring strength and dynamic stability in elite academy footballers. SCI MED FOOTBALL 2022; 5:48-54. [PMID: 35073230 DOI: 10.1080/24733938.2020.1782458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Previous research describes dynamic stability and functional strength as key aetiological risk factors associated with lower limb non-contact musculoskeletal injury. Due to the multifactorial nature of injury risk, relationships between the two factors will inform injury management and training design. METHODS A total of 59 elite academy footballers from two English premier league category 1-status academies completed the study. All players completed measures of eccentric hamstring strength and dynamic stability. Relationships between directional stability (Anteroposterior (Ant), Posteromedial (PM) and Posterolateral (PL)) and eccentric strength metrics (PkT, AvT, PkF, AvF and Ɵ) bilaterally were identified for analysis. RESULTS Significant correlations were identified bilaterally for functional hamstring strength metrics and PM and PL stability (P ≤. 0.05). No significant relationships were identified between anterior stability and eccentric hamstring strength parameters (P > 0.05). CONCLUSIONS Eccentric hamstring strength has a positive influence on directional stability through two planes, PM and PL. The lack of influence of eccentric hamstring strength on Ant directional stability could be attributed to increased ACL risk. Careful consideration of the significance of the relationships between eccentric hamstring strength and directional stability must be given when quantifying injury risk in elite academy footballers.
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Affiliation(s)
- David Rhodes
- University of Central Lancashire, Preston, Lancashire, UK
| | | | | | - Antony Reedy
- Academy Sports Science and Medicine, Burnley FC, Gawthorpe Park, Padiham, UK
| | - Erin Morehead
- University of Central Lancashire, Preston, Lancashire, UK
| | - John Kiely
- University of Central Lancashire, Preston, Lancashire, UK
| | | | - Chris Carling
- University of Central Lancashire, Preston, Lancashire, UK
| | - Jill Alexander
- University of Central Lancashire, Preston, Lancashire, UK
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The Temporal Pattern of Recovery in Directional Dynamic Stability Post Football-Specific Fatigue. J Sport Rehabil 2021; 30:1047-1052. [PMID: 34050039 DOI: 10.1123/jsr.2020-0284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 03/04/2021] [Accepted: 03/21/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Rising injury rates within football require further understanding of the etiological risk factors associated with lower-limb injury. AIM To examine the temporal pattern of recovery of directional dynamic stability measures post football-specific fatigue. METHODS Eighteen male elite footballers completed baseline assessments of directional dynamic stability measures (Overall Stability Index, anterior-posterior stability [A-P], medial-lateral stability [M-L] on level 1 of the Biodex Stability System). Post Soccer-Specific Aerobic Field Test90 measures were repeated immediately, +24 hours, +48 hours, and +72 hours. The main effects for the recovery time and direction of stability were supplemented by regression modeling to describe the temporal pattern of recovery. RESULTS Significant main effects for time were identified for all directions of stability (Overall Stability Index, A-P, and M-L) up to +48 hours postexercise (P ≤ .05). The quadratic pattern of temporal recovery highlights a minimum of 37.55 to 38.67 hours and maximum of 75.09 to 77.33 hours. Additionally, a main effect for direction of stability was observed, with significant differences identified between A-P and M-L stability at all time points (P ≤ .001). CONCLUSIONS Reductions in directional dynamic stability +48 hours postfatigue highlight implications for training design, recovery strategies, and injury management for performance practitioners. Interestingly, A-P stability has been highlighted as being significantly reduced compared with M-L stability at all time points, regardless of the fatigue exposure. Practitioners should consider the reduction of stability in this plane in relation to common mechanisms of injury in the knee to inform injury-risk-reduction strategies.
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Rice D, Lewis G, McNair P. Impaired Regulation of Submaximal Force after ACL Reconstruction: Role of Muscle Spindles. Int J Sports Med 2020; 42:550-558. [PMID: 33176382 DOI: 10.1055/a-1292-4461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ongoing motor deficits are routinely present following anterior cruciate ligament (ACL) reconstruction, including the ability to regulate muscle force. While such deficits are known, it is unclear why this occurs. The goal of the current study was to investigate the potential influence of muscle spindle input on submaximal force regulation and muscle activity at the knee in people following ACL reconstruction. Fourteen participants (8 female) who were 6-24 months post-ACL reconstruction and 15 control participants (8 female) undertook submaximal force matching and force modulation tasks before and after 20 min of vibration applied to the patella tendon. Across all tasks, the ACL reconstruction participants were poorer at force matching (P=0.007). The effect of vibration was not significant in either group for the force matching tasks (P=0.06), although there was a reduction in maximum voluntary contraction post-vibration in the control group (P<0.001). The ACL reconstruction group also showed evidence of greater activation of the medial hamstring muscles in comparison to controls (P=0.04). Individuals who have undergone ACL reconstruction have a diminished ability to accurately match and regulate submaximal muscle force, but this does not appear to be related to impaired muscle spindle input. Neuromuscular retraining programs that involve force regulation tasks may be necessary to optimize rehabilitation after ACL reconstruction.
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Affiliation(s)
- David Rice
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand.,Department of Anaesthesia and Perioperative Medicine, North Shore Hospital, Auckland, New Zealand
| | - Gwyn Lewis
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Peter McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
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Sritharan P, Perraton LG, Munoz MA, Pivonka P, Bryant AL. Muscular Coordination of Single-Leg Hop Landing in Uninjured and Anterior Cruciate Ligament-Reconstructed Individuals. J Appl Biomech 2020; 36:235-243. [PMID: 32659745 DOI: 10.1123/jab.2019-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 08/22/2019] [Accepted: 09/15/2019] [Indexed: 11/18/2022]
Abstract
This study compared lower-limb muscle function, defined as the contributions of muscles to center-of-mass support and braking, during a single-leg hopping task in anterior cruciate ligament-reconstructed (ACLR) individuals and uninjured controls. In total, 65 ACLR individuals and 32 controls underwent a standardized anticipated single-leg forward hop. Kinematics and ground reaction force data were input into musculoskeletal models to calculate muscle forces and to quantify muscle function by decomposing the vertical (support) and fore-aft (braking) ground reaction force components into contributions by individual lower-limb muscles. Four major muscles, the vasti, soleus, gluteus medius, and gluteus maximus, were primarily involved in support and braking in both ACLR and uninjured groups. However, although the ACLR group demonstrated lower peak forces for these muscles (all Ps < .001, except gluteus maximus, P = .767), magnitude differences in these muscles' contributions to support and braking were not significant. ACLR individuals demonstrated higher erector spinae (P = .012) and hamstrings forces (P = .085) to maintain a straighter, stiffer landing posture with more forward lumbar flexion. This altered landing posture may have enabled the ACLR group to achieve similar muscle function to controls, despite muscle force deficits. Our findings may benefit rehabilitation and the development of interventions to enable faster and safer return to sport.
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Spencer A, Davis K, Jacobs C, Johnson D, Ireland ML, Noehren B. Decreased quadriceps force steadiness following anterior cruciate ligament reconstruction is associated with altered running kinematics. Clin Biomech (Bristol, Avon) 2020; 72:58-62. [PMID: 31835112 DOI: 10.1016/j.clinbiomech.2019.11.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/16/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction is associated with quadriceps dysfunction and altered knee mechanics, but the relationship between these outcomes is not clear. Inclusion of metrics such as the stability of torque output could provide additional insights into the relationship between quadriceps dysfunction and knee mechanics. The purposes of this study were to: (1) measure the difference in quadriceps force steadiness between anterior cruciate ligament reconstructed and contralateral limbs; and (2) assess the relationship of quadriceps force steadiness and peak torque with knee flexion excursion during running. METHODS Twenty-eight participants (14 female, age 20 (5) years) underwent quadriceps strength testing and gait analysis. Force steadiness was measured with the standard deviation and coefficient of variation of the participants' detrended torque. Knee flexion excursion was calculated during the stance phase of running trials. Differences between limbs for force steadiness and peak torque were assessed with paired sample t-tests, and a Pearson's product-moment correlation coefficient determined the relationship between pairs of variables. FINDINGS Anterior cruciate ligament reconstructed limbs presented with a significant deficit in relative force steadiness compared to the contralateral limb (4.03 (1.04) % and 3.58 (1.41) % (P < .05), respectively). In addition, the relationship of quadriceps strength and force steadiness with knee flexion excursion was altered in anterior cruciate ligament reconstructed limbs due to the inability of the quadriceps to sustain a controlled force output. INTERPRETATION These results suggest that considering both the magnitude and quality of force production can provide important insight into comprehensive quadriceps function.
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Affiliation(s)
- Alex Spencer
- College of Health Sciences, Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY 40508, USA.
| | - Kylie Davis
- College of Health Sciences, Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY 40508, USA
| | - Cale Jacobs
- College of Medicine, Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40508, USA
| | - Darren Johnson
- College of Medicine, Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40508, USA
| | - Mary Lloyd Ireland
- College of Medicine, Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40508, USA
| | - Brian Noehren
- College of Health Sciences, Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY 40508, USA; College of Medicine, Department of Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY 40508, USA
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Diagnostic Validity of an Isokinetic Testing to Identify Partial Anterior Cruciate Ligament Injuries. J Sport Rehabil 2019; 29:1086-1092. [PMID: 31825887 DOI: 10.1123/jsr.2019-0195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/18/2019] [Accepted: 10/01/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the diagnostic validity of an isokinetic testing to detect partial injuries on the anterior cruciate ligament (ACL). DESIGN Prospective diagnostic study. SETTINGS Orthopedic clinic, physiotherapy clinic, orthopedic hospital, and diagnostic/image clinic. PARTICIPANTS Consecutive patients (n = 29) with unilateral knee complaint submitted to physical examination, magnetic resonance images (MRIs), and isokinetic testing prior to surgery of ACL reconstruction. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The isokinetic torque curves data from extensor and flexor muscles were converted to frequency domain by fast Fourier transformation and compared with healthy contralateral limb. Differences were categorized as unstable knees and these conclusions were compared with patient's physical examinations (doctor's conclusion on ACL integrity) and MRIs (as the radiologist conclusions on ACL integrity). After surgery, all intraoperatively confirmed partial injured patient's data were collected. The diagnostic accuracy measures to compare the conclusions of all 3 professionals included sensitivity, specificity, positive predictive value, negative predictive value, disease prevalence, positive likelihood ratio, and accuracy-all using a confidence interval of 95%. RESULTS Compared with MRI, the sensitivity of isokinetic test for an ACL partial injury was 90.00%, specificity 83.33%, positive predictive value 52.94%, negative predictive value 97.56%, and accuracy 84.48%. Compared with physical examination, the sensitivity of isokinetic test for an ACL partial injury was 85.71%, specificity 78.43%, positive predictive value 35.29%, negative predictive value 97.56%, and accuracy 79.31%. CONCLUSIONS This method of isokinetic data analysis through fast Fourier transformation can be used to improve diagnostic accuracy of a difficult detection injury. Even present, a partial ACL injury can produce a stable knee during isokinetic testing and could be used to detect candidates for conservative treatment based on strengthening exercises, reducing surgery risks, and financial and social impact on patient's life.
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Ward SH, Perraton L, Bennell K, Pietrosimone B, Bryant AL. Deficits in Quadriceps Force Control After Anterior Cruciate Ligament Injury: Potential Central Mechanisms. J Athl Train 2019; 54:505-512. [PMID: 31009232 DOI: 10.4085/1062-6050-414-17] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
CONTEXT Poor quadriceps force control has been observed after anterior cruciate ligament (ACL) reconstruction but has not been examined after ACL injury. Whether adaptations within the central nervous system are contributing to these impairments is unknown. OBJECTIVE To examine quadriceps force control in individuals who had sustained a recent ACL injury and determine the associations between cortical excitability and quadriceps force control in these individuals. DESIGN Cross-sectional study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS Eighteen individuals with a recent unilateral ACL injury (6 women, 12 men; age = 29.6 ± 8.4 years, height = 1.74 ± 0.07 m, mass = 76.0 ± 10.4 kg, time postinjury = 69.5 ± 42.5 days) and 18 uninjured individuals (6 women, 12 men; age = 29.2 ± 6.8 years, height = 1.79 ± 0.07 m, mass = 79.0 ± 8.4 kg) serving as controls participated. MAIN OUTCOME MEASURE(S) Quadriceps force control was quantified as the root mean square error between the quadriceps force and target force during a cyclical force-matching task. Cortical excitability was measured as the active motor threshold and cortical silent period. Outcome measures were determined bilaterally in a single testing session. Group and limb differences in quadriceps force control were assessed using mixed analyses of variance (2 × 2). Pearson product moment correlations were performed between quadriceps force control and cortical excitability in individuals with an ACL injury. RESULTS Individuals with an ACL injury exhibited greater total force-matching error with their involved (standardized mean difference [SMD] = 0.8) and uninvolved (SMD = 0.9) limbs than did controls (F1,27 = 11.347, P = .03). During the period of descending force, individuals with an ACL injury demonstrated greater error using their involved (SMD = 0.8) and uninvolved (SMD = 0.8) limbs than uninjured individuals (F1,27 = 4.941, P = .04). Greater force-matching error was not associated with any cortical excitability measures (P > .05). CONCLUSIONS Quadriceps force control was impaired bilaterally after recent ACL injury but was not associated with selected measures of cortical excitability. The findings highlight a need to incorporate submaximal-force control tasks into rehabilitation and "prehabilitation," as the deficits were present before surgery.
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Affiliation(s)
- Sarah H Ward
- Centre for Health, Exercise and Sports Medicine, University of Melbourne, Victoria, Australia.,Dr Ward is now with the Insight Centre for Data Analytics, University College Dublin, Ireland
| | - Luke Perraton
- Centre for Health, Exercise and Sports Medicine, University of Melbourne, Victoria, Australia
| | - Kim Bennell
- Centre for Health, Exercise and Sports Medicine, University of Melbourne, Victoria, Australia
| | - Brian Pietrosimone
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Adam L Bryant
- Centre for Health, Exercise and Sports Medicine, University of Melbourne, Victoria, Australia
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San Martín-Mohr C, Cristi-Sánchez I, Pincheira PA, Reyes A, Berral FJ, Oyarzo C. Knee sensorimotor control following anterior cruciate ligament reconstruction: A comparison between reconstruction techniques. PLoS One 2018; 13:e0205658. [PMID: 30439952 PMCID: PMC6237303 DOI: 10.1371/journal.pone.0205658] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 09/29/2018] [Indexed: 12/18/2022] Open
Abstract
The sensorimotor system helps to maintain functional joint stability during movement. After anterior cruciate ligament (ACL) injury and reconstruction, several sensorimotor deficits may arise, including altered proprioception and changes in neuromuscular control. It is still unknown whether the type of autograft used in the reconstruction may influence knee sensorimotor impairments. The aim of this study was to comparatively assess the effects of the hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) ACL reconstruction techniques on knee sensorimotor control 6–12 months post-operation. A total of 83 male subjects participated in this study: 27 healthy participants, 30 BPTB-operated patients and 26 HT-operated patients. Active joint position sense in 3 ranges of motion (90–60°, 60–30°, and 30–0° of knee flexion), isometric steadiness, and onset of muscle activation were used to compare sensorimotor system function between groups. Both operated groups had a small (< 5°) but significant joint position sense error in the 30–0° range when compared to the healthy group. No significant differences were found between the operated and the control groups for isometric steadiness or onset of muscle activation. The results of this study suggest that operated patients present knee proprioceptive deficits independently of surgical technique. Nevertheless, the clinical implications of this impairment are still unknown. It seems that selected surgical approach for ACL reconstruction do not affect functioning of the sensorimotor system to a large degree.
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Affiliation(s)
- Cristóbal San Martín-Mohr
- Carrera de Kinesiología, Departamento Ciencias de la salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Clínica MEDS, Santiago, Chile
- * E-mail:
| | - Iver Cristi-Sánchez
- Clínica MEDS, Santiago, Chile
- Escuela de Kinesiología, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
| | - Patricio A. Pincheira
- Escuela de Kinesiología, Facultad de Ciencias, Universidad Mayor, Santiago, Chile
- Laboratorio Integrativo Biomecánica y Fisiología del Ejercicio, Escuela de Kinesiología, Universidad de los Andes, Santiago, Chile
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia
| | - Alvaro Reyes
- Facultad de Ciencias de la Rehabilitación, Universidad Andrés Bello, Santiago, Chile
| | | | - Claudio Oyarzo
- Clínica MEDS, Santiago, Chile
- Universidad de Los Andes, Santiago, Chile
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Iacono AD, Buksbaum C, Padulo J, Hetsroni I, Ben-Sira D, Ayalon M. Isokinetic moment curve abnormalities are associated with articular knee lesions. Biol Sport 2018; 35:83-91. [PMID: 30237665 PMCID: PMC6135969 DOI: 10.5114/biolsport.2018.71486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/27/2017] [Accepted: 06/16/2017] [Indexed: 01/07/2023] Open
Abstract
The aim of this study was to test whether lesions of the medial meniscus (MM) and of the anterior cruciate ligament (ACL) are associated with specific abnormalities of isokinetic moment curves (IMCs). Fifty-four young adults (20 active healthy people, and 34 patients with unilateral knee injuries) were assessed through knee extensor and flexor isokinetic tests at 60°/s. Qualitative IMC analysis was performed using a novel classification system which identified three distinct abnormal shapes. The chi-squared (χ2) test was used to determine the inter-individual and intra-individual differences between the groups. Quantitative IMC inter-group comparisons were performed by a one-way analysis of variance (ANOVA). Knees with MM and ACL lesions were consistently associated with IMC shape irregularities (p<0.001) and with abnormal quantitative scores (p<0.001). More specifically, knees with isolated ACL lesions and knees with combined ACL and MM lesions presented similar distribution of knee extensor and flexor IMC irregularities, which was not present in knees with isolated MM lesions. A possible association between specific knee pathologies and IMC irregularities was identified (all p<0.05). In conclusion, different knee pathologies may be associated with different qualitative IMCs, which could be used as an additional presentation tool in clinical settings.
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Affiliation(s)
- Antonio Dello Iacono
- Zinman College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Chen Buksbaum
- Zinman College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Johnny Padulo
- University eCampus, Novedrate, Italy
- University of Split, Faculty of Kinesiology, Split, Croatia
| | - Iftach Hetsroni
- Department of Orthopedic Surgery, Meir General Hospital, Kfar Saba, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Ben-Sira
- Zinman College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
| | - Moshe Ayalon
- Zinman College of Physical Education and Sport Sciences, Wingate Institute, Netanya, Israel
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Impaired voluntary quadriceps force control following anterior cruciate ligament reconstruction: relationship with knee function. Knee Surg Sports Traumatol Arthrosc 2017; 25:1424-1431. [PMID: 26745965 DOI: 10.1007/s00167-015-3937-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/09/2015] [Indexed: 12/15/2022]
Abstract
PURPOSE Impairments in quadriceps force control and altered quadriceps and hamstring muscle activation strategies have been observed following anterior cruciate ligament reconstruction; however, the functional implications of these impairments are unclear. This study examined the cross-sectional associations between quadriceps force control, quadriceps activation, hamstring coactivation and clinically assessed knee function following anterior cruciate ligament reconstruction with a hamstring graft. METHODS Sixty-six patients (18 ± 3 months following surgery) and 41 uninjured individuals participated. Quadriceps force control was assessed using an isometric knee extension task. Participants cyclically increased and decreased quadriceps force at slow speeds between 5 and 30 % maximum voluntary isometric contraction matching a moving target displayed on a screen. Quadriceps activation and hamstring coactivation were assessed concurrently using surface electromyography. Knee function was assessed with the Cincinnati Knee Rating Scale and three single-leg hop tests. RESULTS The reconstructed group completed the task with 48 % greater root-mean-square error (RMSE), indicating significantly worse quadriceps force control (p < 0.001). In a multivariable model adjusted for sex, greater RMSE and greater lateral hamstring coactivation were significantly associated with worse knee function that is greater odds of scoring <85 % on one or more knee functional assessment. CONCLUSIONS Less-accurate quadriceps force output and greater hamstring coactivation are associated with worse knee joint function following anterior cruciate ligament reconstruction and may contribute to irregular knee joint loading and the onset or progression of knee osteoarthritis. Impairments in quadriceps force control and altered muscle activation strategies may be modifiable through neuromuscular training, and this is an area for future research. LEVEL OF EVIDENCE Case-control study, Level III.
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Almosnino S, Dvir Z, Bardana DD. Consistency of strength curves for determining maximal effort production during isokinetic knee testing of anterior cruciate ligament-deficient patients. Physiother Theory Pract 2016; 32:202-8. [PMID: 27043046 DOI: 10.3109/09593985.2015.1137092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this investigation was to attempt to establish decision rules for determining maximal effort production during isokinetic strength testing of unilateral anterior cruciate ligament-deficient patients based on the degree of strength curve consistency within a set. Thirty-three participants performed six bilateral knee extension and flexion exertions at maximal effort and at 80% of perceived maximum at testing velocities of 60 and 180°s(-1). Within-set consistency was quantified by computation of the variance ratio across strength curves. Tolerance interval-based cutoff scores covering 99% of the population were calculated for declaring efforts as being maximal or not at confidence levels of 90%, 95%, and 99%. The sensitivity percentages attained for the injured knee for both testing velocities ranged between 9.1% and 27.2%, while specificity percentages ranged between 84.8% and 100%. For the non-injured knee, sensitivity values for both testing velocities ranged between 21.2% and 45.0%, while specificity percentages ranged between 97.0% and 100%. The developed decision rules do not effectively discriminate on an individual patient basis between maximal and non-maximal isokinetic knee musculature efforts. Further research is needed for development of methods that would enable to ascertain maximal effort production in this patient population during knee muscle strength testing.
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Affiliation(s)
- Sivan Almosnino
- a Resource Environmental Associates, Ltd ., Markham , ON , Canada
| | - Zeevi Dvir
- b Department of Physical Therapy, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Davide D Bardana
- c Department of Orthopedic Surgery , Kingston General Hospital , Kingston , ON , Canada
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Rice DA, McNair PJ, Lewis GN, Mannion J. Experimental knee pain impairs submaximal force steadiness in isometric, eccentric, and concentric muscle actions. Arthritis Res Ther 2015; 17:259. [PMID: 26377678 PMCID: PMC4574021 DOI: 10.1186/s13075-015-0768-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 08/26/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Populations with knee joint damage, including arthritis, have noted impairments in the regulation of submaximal muscle force. It is difficult to determine the exact cause of such impairments given the joint pathology and associated neuromuscular adaptations. Experimental pain models that have been used to isolate the effects of pain on muscle force regulation have shown impaired force steadiness during acute pain. However, few studies have examined force regulation during dynamic contractions, and these findings have been inconsistent. The goal of the current study was to examine the effect of experimental knee joint pain on submaximal quadriceps force regulation during isometric and dynamic contractions. METHODS The study involved fifteen healthy participants. Participants were seated in an isokinetic dynamometer. Knee extensor force matching tasks were completed in isometric, eccentric, and concentric muscle contraction conditions. The target force was set to 10 % of maximum for each contraction type. Hypertonic saline was then injected into the infrapatella fat pad to generate acute joint pain. The force matching tasks were repeated during pain and once more 5 min after pain had subsided. RESULTS Hypertonic saline resulted in knee pain with an average peak pain rating of 5.5 ± 2.1 (0-10 scale) that lasted for 18 ± 4 mins. Force steadiness significantly reduced during pain across all three muscle contraction conditions. There was a trend to increased force matching error during pain but this was not significant. CONCLUSION Experimental knee pain leads to impaired quadriceps force steadiness during isometric, eccentric, and concentric contractions, providing further evidence that joint pain directly affects motor performance. Given the established relationship between submaximal muscle force steadiness and function, such an effect may be detrimental to the performance of tasks in daily life. In order to restore motor performance in people with painful arthritic conditions of the knee, it may be important to first manage their pain more effectively.
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Affiliation(s)
- David A Rice
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand. .,Waitemata Pain Service, Department of Anaesthesia and Perioperative Medicine, North Shore Hospital, Private Bag 93-503, Takapuna, Auckland, New Zealand.
| | - Peter J McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand.
| | - Gwyn N Lewis
- Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand.
| | - Jamie Mannion
- Unitec Institute of Technology, Private Bag 92025, Victoria St West, Auckland, New Zealand.
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Pua YH, Ong PH, Ho JY, Bryant AL, E Webster K, Clark RA. Associations of isokinetic knee steadiness with hop performance in patients with ACL deficiency. Knee Surg Sports Traumatol Arthrosc 2015; 23:2185-2195. [PMID: 24756538 DOI: 10.1007/s00167-014-2995-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 04/06/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE Contrary to the ample data available regarding the functional significance of isokinetic knee strength in patients with anterior cruciate ligament deficiency (ACLD), much less is known about the functional significance of isokinetic knee steadiness. This cross-sectional study aimed to evaluate, in patients with ACLD, the independent impact of isokinetic quadriceps and hamstrings torque steadiness on single-leg hop performance. METHODS Eighty-seven patients with unilateral ACLD participated. Patients performed isokinetic quadriceps and hamstrings steadiness and strength testing at 60°/s on an isokinetic dynamometer. Muscle steadiness and strength were represented by the wavelet-derived mean instantaneous frequency and peak value of the torque-time curves, respectively. To measure hop performance, patients performed a single-leg hop for distance and a 6-m single-leg hop for velocity. RESULTS One of two patients [n = 45 (51 %)] had a 10 % or greater difference in knee torque frequency levels between the ACLD and contralateral knees. In multivariable models adjusted for age, sex, knee pain, and knee strength, hamstrings steadiness was significantly related with hop velocity whilst quadriceps steadiness was significantly related with both hop distance and velocity. Variance decomposition analyses suggested that quadriceps steadiness was similar in importance to hamstrings strength on hop distance and velocity. CONCLUSIONS In patients with ACLD, isokinetic knee steadiness deficits were common and were independently associated with single-leg hop performance. Knee torque steadiness-a heretofore understudied variable-may prove a useful adjunct to conventional peak torque measurements by offering additional information to researchers and rehabilitation professionals about muscle performance and neuromuscular knee control. LEVEL OF EVIDENCE Prognostic studies, Level III.
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Affiliation(s)
- Yong-Hao Pua
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Peck-Hoon Ong
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Jia-Ying Ho
- Department of Physiotherapy, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Adam L Bryant
- Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Kate E Webster
- School of Health Sciences Research, La Trobe University, Melbourne, Australia
| | - Ross A Clark
- School of Exercise Science, Australian Catholic University, Melbourne, Australia
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Wang JH, Hsu WL, Lee SC, Wang TG, Rolf C, Su SC, Shih TTF, Wang HK. Neuromechanical characteristics in the knees of patients who had primary conservative treatment for a torn cruciate ligament and reconstruction afterward. J Formos Med Assoc 2015; 114:1240-9. [PMID: 25624115 DOI: 10.1016/j.jfma.2014.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND/PURPOSE To compare the neuromechanical characteristics and subjective outcomes for knees of patients with a cruciate ligament tear and reconstruction with those for knees of controls at three time intervals, and to determine correlations between the characteristics and subjective outcomes. METHODS Ten participants with a cruciate ligament tear and at least a 12-week conservative treatment prior to ligament reconstruction were prospectively measured prior to and 3 months and 6 months after surgery. Ten healthy individuals were recruited as controls. Questionnaire surveys regarding the injured knee were conducted, as were bilateral measurements of root mean square electromyography (EMG), the rate of EMG rise, the median frequency in the vastus medialis of the quadriceps muscles and antagonist coactivation from the semitendinosus muscle, and force capacities, including peak torque, rate of force development, and total works of the knee extension. Correlations between the EMG variables (of the vastus medialis and semitendinosus) and the force capacities, and between the EMG variables and the knee injury and osteoarthritis outcome scores (KOOS), and between force capacities and the KOOS were assessed in the participants with a ligament reconstruction. RESULTS Pre- and postoperative results of EMG variable and force capacities were lower in both knees of the experimental group participants than in the control group participants (all p < 0.05). Correlations between EMG and force capacities, and between these parameters and the KOOS were found. CONCLUSION There were bilateral neuromechanical defects in the knees of the participants who had undergone conservative treatment as well as reconstruction after a cruciate ligament tear.
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Affiliation(s)
- Jyh-Horng Wang
- Department of Orthopedic Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC; Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Wei-Li Hsu
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC; Center of Physical Therapy, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Song-Ching Lee
- Department of Physical Medicine & Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Tyng-Guey Wang
- Department of Physical Medicine & Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan, ROC; Department of Rehabilitation, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Christer Rolf
- Department of Orthopaedics, Clintec, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sheng-Chu Su
- Department of Business Administration, Hwa Hsia Institute of Technology, Taipei, Taiwan, ROC
| | - Tiffany T F Shih
- Department of Medical Image, National Taiwan University Hospital, Taipei, Taiwan, ROC; Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Hsing-Kuo Wang
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC; Center of Physical Therapy, National Taiwan University Hospital, Taipei, Taiwan, ROC.
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Telianidis S, Perraton L, Clark RA, Pua YH, Fortin K, Bryant AL. Diminished sub-maximal quadriceps force control in anterior cruciate ligament reconstructed patients is related to quadriceps and hamstring muscle dyskinesia. J Electromyogr Kinesiol 2014; 24:513-9. [PMID: 24875460 DOI: 10.1016/j.jelekin.2014.04.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/28/2014] [Accepted: 04/23/2014] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to determine the effects of anterior cruciate ligament reconstruction (ACLR) on sub-maximal quadriceps force control with respect to quadriceps and hamstring muscle activity. Thirty ACLR individuals together with 30 healthy individuals participated. With real-time visual feedback of muscle force output and electromyographic electrodes attached to the quadriceps and hamstring muscles, subjects performed an isometric knee extension task where they increased and decreased their muscle force output at 0.128Hz within a range of 5-30% maximum voluntary capacity. The ACLR group completed the task with more error and increased medial hamstring and vastus medialis activation (p<0.05). Moderate negative correlations (p<0.05) were observed between quadriceps force control and medial (Spearman's rho=-0.448, p=0.022) and lateral (Spearman's rho=-0.401, p=0.034) hamstring activation in the ACLR group. Diminished quadriceps sub-maximal force control in ACLR subjects was reflective of medial quadriceps and hamstring dyskinesia (i.e., altered muscle activity patterns and coordination deficits). Within the ACLR group however, augmented hamstring co-activation was associated with better quadriceps force control. Future studies should explore the convergent validity of quadriceps force control in ACLR patients.
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Affiliation(s)
- Stacey Telianidis
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne 3010, VIC, Australia
| | - Luke Perraton
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne 3010, VIC, Australia
| | - Ross A Clark
- School of Exercise Science, Faculty of Health Sciences, Australian Catholic University, Melbourne VIC, Australia
| | - Yong-Hao Pua
- Department of Physiotherapy, Singapore General Hospital, Singapore
| | - Karine Fortin
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne 3010, VIC, Australia
| | - Adam L Bryant
- Department of Physiotherapy, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne 3010, VIC, Australia.
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Ascertaining Maximal Voluntary Effort Production During Isokinetic Knee Strength Testing of Anterior Cruciate Ligament–Reconstructed Patients. Am J Phys Med Rehabil 2014; 93:169-81. [DOI: 10.1097/phm.0000000000000041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Principal component modeling of isokinetic moment curves for discriminating between the injured and healthy knees of unilateral ACL deficient patients. J Electromyogr Kinesiol 2013; 24:134-43. [PMID: 24280243 DOI: 10.1016/j.jelekin.2013.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 09/29/2013] [Accepted: 10/24/2013] [Indexed: 11/23/2022] Open
Abstract
Bilateral knee strength evaluations of unilateral anterior cruciate ligament (ACL) deficient patients using isokinetic dynamometry are commonly performed in rehabilitation settings. The most frequently-used outcome measure is the peak moment value attained by the knee extensor and flexor muscle groups. However, other strength curve features may also be of clinical interest and utility. The purpose of this investigation was to identify, using Principal Component Analysis (PCA), strength curve features that explain the majority of variation between the injured and uninjured knee, and to assess the capabilities of these features to detect the presence of injury. A mixed gender cohort of 43 unilateral ACL deficient patients performed 6 continuous concentric knee extension and flexion repetitions bilaterally at 60°s(-1) and 180°s(-1) within a 90° range of motion. Moment waveforms were analyzed using PCA, and binary logistic regression was used to develop a discriminatory decision rule. For all directions and speeds, a statistically significant overall reduction in strength was noted for the involved knee in comparison to the uninvolved knee. The discriminatory decision rule yielded a specificity and sensitivity of 60.5% and 60.5%, respectively, corresponding to an accuracy of ∼62%. As such, the curve features extracted using PCA enabled only limited clinical usefulness in discerning between the ACL deficient and contra lateral, healthy knee. Improvement in discrimination capabilities may perhaps be achieved by consideration of different testing speeds and contraction modes, as well as utilization of other data analysis techniques.
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Neuromuscular training to target deficits associated with second anterior cruciate ligament injury. J Orthop Sports Phys Ther 2013; 43:777-792, A1-11. [PMID: 24175599 PMCID: PMC4163697 DOI: 10.2519/jospt.2013.4693] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SYNOPSIS Successful return to previous level of activity following anterior cruciate ligament (ACL) reconstruction is not guaranteed, and the prevalence of second ACL injury may be as high as 30%. In particular, younger athletes who return to sports activities within the first several months after ACL reconstruction may be at significantly greater risk of a second ACL rupture compared to older, less active individuals. Significant neuromuscular deficits and functional limitations are commonly identified in athletes following ACL reconstruction, and these abnormal movement and neuromuscular control profiles may be both residual of deficits existing prior to the initial injury and exacerbated by the injury and subsequent ACL reconstruction surgery. Following ACL reconstruction, neuromuscular deficits are present in both the surgical and nonsurgical limbs, and accurately predict second-ACL injury risk in adolescent athletes. While second ACL injury in highly active individuals may be predicated on a number of modifiable and nonmodifiable factors, clinicians have the greatest potential to address the modifiable postsurgical risk factors through targeted neuromuscular interventions. This manuscript will (1) summarize the neuromuscular deficits commonly identified at medical discharge to return to sport, (2) provide the evidence underlying second-ACL injury risk factors, (3) propose a method to assess the modifiable deficits related to second-ACL injury risk, and (4) outline a method of intervention to prevent second ACL injury. The program described in this clinical commentary was developed with consideration for the modifiable factors related to second-injury risk, the principles of motor learning, and careful selection of the exercises that may most effectively modify aberrant neuromuscular patterns. Future validation of this evidence-based, late-phase rehabilitation program may be a critical factor in maximizing return-to-activity success and reduction of second-injury risk in highly active individuals. LEVEL OF EVIDENCE Therapy, level 5.
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Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41:216-24. [PMID: 23041233 PMCID: PMC3592333 DOI: 10.1177/0363546512459638] [Citation(s) in RCA: 258] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ligament reconstruction is the current standard of care for active patients with an anterior cruciate ligament (ACL) rupture. Although the majority of ACL reconstruction (ACLR) surgeries successfully restore the mechanical stability of the injured knee, postsurgical outcomes remain widely varied. Less than half of athletes who undergo ACLR return to sport within the first year after surgery, and it is estimated that approximately 1 in 4 to 1 in 5 young, active athletes who undergo ACLR will go on to a second knee injury. The outcomes after a second knee injury and surgery are significantly less favorable than outcomes after primary injuries. As advances in graft reconstruction and fixation techniques have improved to consistently restore passive joint stability to the preinjury level, successful return to sport after ACLR appears to be predicated on numerous postsurgical factors. Importantly, a secondary ACL injury is most strongly related to modifiable postsurgical risk factors. Biomechanical abnormalities and movement asymmetries, which are more prevalent in this cohort than previously hypothesized, can persist despite high levels of functional performance, and also represent biomechanical and neuromuscular control deficits and imbalances that are strongly associated with secondary injury incidence. Decreased neuromuscular control and high-risk movement biomechanics, which appear to be heavily influenced by abnormal trunk and lower extremity movement patterns, not only predict first knee injury risk but also reinjury risk. These seminal findings indicate that abnormal movement biomechanics and neuromuscular control profiles are likely both residual to, and exacerbated by, the initial injury. Evidence-based medicine (EBM) strategies should be used to develop effective, efficacious interventions targeted to these impairments to optimize the safe return to high-risk activity. In this Current Concepts article, the authors present the latest evidence related to risk factors associated with ligament failure or a secondary (contralateral) injury in athletes who return to sport after ACLR. From these data, they propose an EBM paradigm shift in postoperative rehabilitation and return-to-sport training after ACLR that is focused on the resolution of neuromuscular deficits that commonly persist after surgical reconstruction and standard rehabilitation of athletes.
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Affiliation(s)
- Timothy E. Hewett
- Address correspondence to Timothy E. Hewett, PhD, The Sports Health and Performance Institute, The Ohio State University, 2050 Kenny Road, Suite 3100, Columbus, OH 43221 ()
| | | | - Gregory D. Myer
- Address correspondence to Timothy E. Hewett, PhD, The Sports Health and Performance Institute, The Ohio State University, 2050 Kenny Road, Suite 3100, Columbus, OH 43221 ()
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