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      Quadriceps Strength and Volitional Activation After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

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          Abstract

          Context:

          Quadriceps function is a significant contributor to knee joint health that is influenced by central and peripheral factors, especially after anterior cruciate ligament reconstruction (ACLR).

          Objective:

          To assess differences of unilateral quadriceps isometric strength and activation between the involved limb and contralateral limb of individuals with ACLR and healthy controls.

          Data Sources:

          Web of Science, SportDISCUS, PubMed, CINAHL, and the Cochrane Database were all used during the search.

          Study Selection:

          A total of 2024 studies were reviewed. Twenty-eight studies including individuals with a unilateral history of ACLR, isometric knee extension strength normalized to body mass, and quadriceps activation measured by central activation ratios (CARs) through a superimposed burst technique were identified for meta-analysis. The methodological quality of relevant articles was assessed using a modified Downs and Black scale. Results of methodological quality assessment ranged from low to high quality (low, n = 10; moderate, n = 8; high, n = 10).

          Study Design:

          Meta-analysis.

          Level of Evidence:

          Level 2.

          Data Extraction:

          Means, standard deviations, and sample sizes were extracted from articles, and magnitude of between-limb and between-group differences were evaluated using a random-effects model meta-analysis approach to calculate combined pooled effect sizes (ESs) and 95% CIs. ESs were classified as weak ( d < 0.19), small ( d = 0.20-0.49), moderate ( d = 0.50-0.79), or large ( d > 0.80).

          Results:

          The involved limb of individuals with ACLR displayed lower knee extension strength compared with the contralateral limb (ES, –0.78; lower bound [LB], –0.99; upper bound [UB], –0.58) and healthy controls (ES, –0.76; LB, –0.98; UB, –0.53). The involved limb displayed a lower CAR compared with healthy controls (ES, –0.84; LB, –1.18; UB, –0.50) but not compared with the contralateral limb (ES, –0.15; LB, –0.37; UB, 0.07). The ACLR contralateral limb displayed a lower CAR (ES, –0.73; LB, –1.39; UB, –0.07) compared with healthy control limbs but similar knee extension strength (ES, –0.24; LB, –0.68; UB, –0.19).

          Conclusion:

          Individuals with ACLR have bilateral CAR deficits and involved limb strength deficits that persist years after surgery. Deficits in quadriceps function may have meaningful implications for patient-reported and objective outcomes, risk of reinjury, and long-term joint health after ACLR.

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          Most cited references50

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          Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery.

          An athlete's desire to return to sport after anterior cruciate ligament (ACL) injury is a major indication for ACL reconstruction surgery. Typical clearance to return is 6 to 12 months postoperatively. To investigate the return-to-sport rate and participation level of a large cohort at 12 months after ACL reconstruction surgery. Case series; Level of evidence, 4. Data were analyzed for 503 patients who participated in competitive-level Australian football, basketball, netball, or soccer after ACL reconstruction surgery using a quadruple-strand hamstring autograft. Inclusion criteria included participation in competitive sport before the ACL injury and clearance from the orthopaedic surgeon to return to sport postoperatively. Patients completed a self-report questionnaire regarding preoperative and postoperative sports participation and the Cincinnati Sports Activity Scale. The International Knee Documentation Committee (IKDC) knee evaluation form and hop tests were used to evaluate knee function. Sixty-seven percent of patients attempted some form of sports activity by 12 months postoperatively; 33% attempted competitive sport. Of those who did not attempt any sports activity by 12 months, 47% indicated that they were planning to return. Men were significantly more likely than women to return. Patients who played sports with a seasonal competition, versus a year-round competition, were significantly more likely to return by 12 months. Patients with normal postoperative knee function (IKDC category A), versus those with nearly normal function (IKDC category B), were no more likely to return, but patients with good hop test results (≥85% limb symmetry index) were more likely to return than patients with poor results (<85%). People may require a longer postoperative rehabilitation period than that typically advocated to facilitate a successful return to competitive sport after ACL reconstruction surgery. The relationship between postoperative knee function and return-to-sport outcomes at 12 months after surgery was inconclusive.
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            Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury.

            Study Design Prospective cohort. Background The high risk of second anterior cruciate ligament (ACL) injuries after return to sport highlights the importance of return-to-sport decision making. Objective return-to-sport criteria frequently use limb symmetry indexes (LSIs) to quantify quadriceps strength and hop scores. Whether using the uninvolved limb in LSIs is optimal is unknown. Objectives To evaluate the uninvolved limb as a reference standard for LSIs utilized in return-to-sport testing and its relationship with second ACL injury rates. Methods Seventy athletes completed quadriceps strength and 4 single-leg hop tests before anterior cruciate ligament reconstruction (ACLR) and 6 months after ACLR. Limb symmetry indexes for each test compared involved-limb measures at 6 months to uninvolved-limb measures at 6 months. Estimated preinjury capacity (EPIC) levels for each test compared involved-limb measures at 6 months to uninvolved-limb measures before ACLR. Second ACL injuries were tracked for a minimum follow-up of 2 years after ACLR. Results Forty (57.1%) patients achieved 90% LSIs for quadriceps strength and all hop tests. Only 20 (28.6%) patients met 90% EPIC levels (comparing the involved limb at 6 months after ACLR to the uninvolved limb before ACLR) for quadriceps strength and all hop tests. Twenty-four (34.3%) patients who achieved 90% LSIs for all measures 6 months after ACLR did not achieve 90% EPIC levels for all measures. Estimated preinjury capacity levels were more sensitive than LSIs in predicting second ACL injuries (LSIs, 0.273; 95% confidence interval [CI]: 0.010, 0.566 and EPIC, 0.818; 95% CI: 0.523, 0.949). Conclusion Limb symmetry indexes frequently overestimate knee function after ACLR and may be related to second ACL injury risk. These findings raise concern about whether the variable ACL return-to-sport criteria utilized in current clinical practice are stringent enough to achieve safe and successful return to sport. Level of Evidence Prognosis, 2b. J Orthop Sports Phys Ther 2017;47(5):334-338. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7285.
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              Quadriceps activation following knee injuries: a systematic review.

              Arthrogenic muscle inhibition is an important underlying factor in persistent quadriceps muscle weakness after knee injury or surgery. To determine the magnitude and prevalence of volitional quadriceps activation deficits after knee injury. Web of Science database. Eligible studies involved human participants and measured quadriceps activation using either twitch interpolation or burst superimposition on patients with knee injuries or surgeries such as anterior cruciate ligament deficiency (ACLd), anterior cruciate ligament reconstruction (ACLr), and anterior knee pain (AKP). Means, measures of variability, and prevalence of quadriceps activation (QA) failure (<95%) were recorded for experiments involving ACLd (10), ACLr (5), and AKP (3). A total of 21 data sets from 18 studies were initially identified. Data from 3 studies (1 paper reporting data for both ACLd and ACLr, 1 on AKP, and the postarthroscopy paper) were excluded from the primary analyses because only graphical data were reported. Of the remaining 17 data sets (from 15 studies), weighted mean QA in 352 ACLd patients was 87.3% on the involved side, 89.1% on the uninvolved side, and 91% in control participants. The QA failure prevalence ranged from 0% to 100%. Weighted mean QA in 99 total ACLr patients was 89.2% on the involved side, 84% on the uninvolved side, and 98.5% for the control group, with prevalence ranging from 0% to 71%. Thirty-eight patients with AKP averaged 78.6% on the involved side and 77.7% on the contralateral side. Bilateral QA failure was commonly reported in patients. Quadriceps activation failure is common in patients with ACLd, ACLr, and AKP and is often observed bilaterally.
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                Author and article information

                Journal
                Sports Health
                Sports Health
                SPH
                spsph
                Sports Health
                SAGE Publications (Sage CA: Los Angeles, CA )
                1941-7381
                1941-0921
                14 January 2019
                Mar-Apr 2019
                14 January 2020
                : 11
                : 2
                : 163-179
                Affiliations
                []Department of Kinesiology, College of Education, Michigan State University, East Lansing, Michigan
                []Department of Kinesiology, University of Connecticut, Storrs, Connecticut
                [§ ]School of Medicine, Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut
                []Division of Sports Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
                Author notes
                [*] [* ] Caroline Lisee, MEd, ATC, Department of Kinesiology, Michigan State University, 308 West Circle Drive #1, East Lansing, MI 48824 (email: liseecar@ 123456msu.edu ) (Twitter: @CarolineLisee).
                Article
                10.1177_1941738118822739
                10.1177/1941738118822739
                6391557
                30638441
                4b5fdae5-4094-472f-a195-bd4bd6cb067b
                © 2019 The Author(s)
                History
                Categories
                Current Research
                Custom metadata
                March/April 2019

                Sports medicine
                quadriceps function,central activation ratio,isometric knee extension strength,aclr

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