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Hop tests can result in higher limb symmetry index values than isokinetic strength and leg press tests in patients following ACL reconstruction

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Quadriceps weakness is a common clinical sign following anterior cruciate ligament injury and reconstruction surgery (ACLR). The aim of this study was to compare strength deficits and the limb symmetry index (LSI) from three different types of functional tests: isokinetic dynamometry, hop test, and leg press.

Methods

A total of 26 subjects with ACLR (average 8.3 months post-operation) participated in the study. The peak knee extension torque was tested with isokinetic dynamometry at 60/180/300 °/s (ISO60/180/300). Hop distance was tested during single hop (SH) and triple hop (TH). Unilateral peak leg power (POWER) was tested during a bilateral leg press test. LSI was calculated as the ratio of the involved limb over the uninvolved limb values. Pearson correlation coefficients and paired t-tests were used to establish relationships among ISO60/180/300, SH/TH, and POWER values and compare these values between the limbs, respectively. Within-subject one-way analysis of variance (ANOVA) with post hoc analyses was used to compare LSI values among different tests.

Results

ISO60/180/300 values were significantly positively correlated with SH/TH and POWER (P < 0.05), while SH/TH and POWER values were not significantly correlated. Significant limb differences were found in all tests (P = 0.001–0.008). ANOVA revealed significant LSI differences among different tests. Specifically, post hoc analyses revealed that LSI during SH was significantly higher than LSI during ISO60. Similarly, LSI during TH was significantly higher than LSIs from ISO60, ISO180, and POWER tests.

Conclusions

Peak knee extension torque values were positively associated with hop distance and leg power during the leg press test. However, LSI values should be interpreted with caution as hop tests provided significantly higher LSI values than isokinetic testing. Both isokinetic dynamometry and unilateral leg press machine could be used to isolate and strengthen the quadriceps in the involved limb. The current “gold standard” isokinetic testing at slow speed (ISO60) provided the lowest LSI value among all functional tests; therefore, the current study supported a continued use of isokinetic testing when examining individual’s readiness and return-to-sport.

Level of evidence

III.

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References

  1. Barfod KW, Feller JA, Hartwig T, Devitt BM, Webster KE (2019) Knee extensor strength and hop test performance following anterior cruciate ligament reconstruction. Knee 26:149–154

    Article  Google Scholar 

  2. Bell DR, Trigsted SM, Post EG, Walden CE (2016) Hip strength in patients with quadriceps strength deficits after ACL reconstruction. Med Sci Sports Exerc 48:1886–1892

    Article  Google Scholar 

  3. Bieler T, Sobol NA, Andersen LL, Kiel P, Lofholm P, Aagaard P et al (2014) The effects of high-intensity versus low-intensity resistance training on leg extensor power and recovery of knee function after ACL-reconstruction. Biomed Res Int 2014:278512

    Article  Google Scholar 

  4. Ebert JR, Edwards P, Yi L, Joss B, Ackland T, Carey-Smith R et al (2018) Strength and functional symmetry is associated with post-operative rehabilitation in patients following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 26:2353–2361

    Article  Google Scholar 

  5. Gatewood CT, Tran AA, Dragoo JL (2017) The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc 25:501–516

    Article  Google Scholar 

  6. Gokeler A, Welling W, Zaffagnini S, Seil R, Padua D (2017) Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:192–199

    Article  Google Scholar 

  7. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA (2016) Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 50:804–808

    Article  Google Scholar 

  8. Habets B, Staal JB, Tijssen M, van Cingel R (2018) Intrarater reliability of the Humac NORM isokinetic dynamometer for strength measurements of the knee and shoulder muscles. BMC Res Notes 11:15

    Article  Google Scholar 

  9. Hauger AV, Reiman MP, Bjordal JM, Sheets C, Ledbetter L, Goode AP (2018) Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 26:399–410

    Article  Google Scholar 

  10. Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ (2007) Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft. Clin Biomech (Bristol, Avon) 22:543–550

    Article  Google Scholar 

  11. Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC (2018) Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sports Traumatol Arthrosc 26:426–433

    Article  Google Scholar 

  12. Jarvela T, Kannus P, Latvala K, Jarvinen M (2002) Simple measurements in assessing muscle performance after an ACL reconstruction. Int J Sports Med 23:196–201

    Article  CAS  Google Scholar 

  13. Johnson AK, Palmieri-Smith RM, Lepley LK (2018) Contribution of neuromuscular factors to quadriceps asymmetry after anterior cruciate ligament reconstruction. J Athl Train 53:347–354

    Article  Google Scholar 

  14. Jones PA, Bampouras TM (2010) A comparison of isokinetic and functional methods of assessing bilateral strength imbalance. J Strength Cond Res 24:1553–1558

    Article  Google Scholar 

  15. Krishnan C, Williams GN (2011) Factors explaining chronic knee extensor strength deficits after ACL reconstruction. J Orthop Res 29:633–640

    Article  Google Scholar 

  16. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E (2016) Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med 50:946–951

    Article  Google Scholar 

  17. Lephart SM, Kocher MS, Harner CD, Fu FH (1993) Quadriceps strength and functional capacity after anterior cruciate ligament reconstruction. Patellar tendon autograft versus allograft. Am J Sports Med 21:738–743

    Article  CAS  Google Scholar 

  18. Lepley AS, Pietrosimone B, Cormier ML (2018) Quadriceps function, knee pain, and self-reported outcomes in patients with anterior cruciate ligament reconstruction. J Athl Train 53:337–346

    Article  Google Scholar 

  19. Lepley LK, Butterfield TA (2017) Shifting the current clinical perspective: isolated eccentric exercise as an effective intervention to promote the recovery of muscle after injury. J Sport Rehabil 26:122–130

    Article  Google Scholar 

  20. Lepley LK, Wojtys EM, Palmieri-Smith RM (2015) Combination of eccentric exercise and neuromuscular electrical stimulation to improve biomechanical limb symmetry after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon) 30:738–747

    Article  Google Scholar 

  21. Myer GD, Schmitt LC, Brent JL, Ford KR, Barber Foss KD, Scherer BJ et al (2011) Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Orthop Sports Phys Ther 41:377–387

    Article  Google Scholar 

  22. Nagelli CV, Hewett TE (2017) Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and functional considerations. Sports Med 47:221–232

    Article  Google Scholar 

  23. Neeter C, Gustavsson A, Thomee P, Augustsson J, Thomee R, Karlsson J (2006) Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surg Sports Traumatol Arthrosc 14:571–580

    Article  Google Scholar 

  24. Norte GE, Hertel J, Saliba SA, Diduch DR, Hart JM (2018) Quadriceps neuromuscular function in patients with anterior cruciate ligament reconstruction with or without knee osteoarthritis: a cross-sectional study. J Athl Train 53:475–485

    Article  Google Scholar 

  25. Noyes FR, Barber SD, Mangine RE (1991) Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med 19:513–518

    Article  CAS  Google Scholar 

  26. Petschnig R, Baron R, Albrecht M (1998) The relationship between isokinetic quadriceps strength test and hop tests for distance and one-legged vertical jump test following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 28:23–31

    Article  CAS  Google Scholar 

  27. Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR (2007) Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther 87:337–349

    Article  Google Scholar 

  28. Schilaty ND, Bates NA, Hewett TE (2018) Relative dearth of ‘sex differences’ research in sports medicine. J Sci Med Sport 21:440–441

    Article  Google Scholar 

  29. Thomas AC, Villwock M, Wojtys EM, Palmieri-Smith RM (2013) Lower extremity muscle strength after anterior cruciate ligament injury and reconstruction. J Athl Train 48:610–620

    Article  Google Scholar 

  30. Thomee R, Neeter C, Gustavsson A, Thomee P, Augustsson J, Eriksson B et al (2012) Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 20:1143–1151

    Article  Google Scholar 

  31. Thompson JA, Chaudhari AM, Schmitt LC, Best TM, Siston RA (2013) Gluteus maximus and soleus compensate for simulated quadriceps atrophy and activation failure during walking. J Biomech 46:2165–2172

    Article  Google Scholar 

  32. Undheim MB, Cosgrave C, King E, Strike S, Marshall B, Falvey E et al (2015) Isokinetic muscle strength and readiness to return to sport following anterior cruciate ligament reconstruction: is there an association? A systematic review and a protocol recommendation. Br J Sports Med 49:1305–1310

    Article  Google Scholar 

  33. Wellsandt E, Failla MJ, Snyder-Mackler L (2017) Limb symmetry indexes can overestimate knee function after anterior cruciate ligament injury. J Orthop Sports Phys Ther 47:334–338

    Article  Google Scholar 

  34. Wilk KE, Romaniello WT, Soscia SM, Arrigo CA, Andrews JR (1994) The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther 20:60–73

    Article  CAS  Google Scholar 

  35. Xergia SA, Pappas E, Georgoulis AD (2015) Association of the single-limb hop test with isokinetic, kinematic, and kinetic asymmetries in patients after anterior cruciate ligament reconstruction. Sports Health 7:217–223

    Article  Google Scholar 

  36. Yoshida Y, Mizner RL, Snyder-Mackler L (2013) Association between long-term quadriceps weakness and early walking muscle co-contraction after total knee arthroplasty. Knee 20:426–431

    Article  Google Scholar 

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Acknowledgements

The authors would like to acknowledge our subjects for their wiliness to participate in the study and the funding agency: the National Institute of Health (NIH) and grants: R01-AR056259 and R01-AR055563. We thank Mr. Eric M. Crowley from the Mayo Clinic Sports Medicine Center for his assistance in subject recruitment and scheduling. We also thank Mr. Daniel V. Gaz, Mr. Thomas M. Rieck, and staff members from the Mayo Clinic Healthy Living Program for their generosity to let us use their leg press machine.

Funding

The study was funded by National Institutes of Health R01-AR056259, R01-AR055563.

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Authors and Affiliations

  1. Sports Medicine Center, Mayo Clinic, Rochester, MN, USA

    Takashi Nagai, Nathan D. Schilaty, Edward R. Laskowski & Timothy E. Hewett

  2. Biomechanics Laboratories, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA

    Takashi Nagai, Nathan D. Schilaty & Timothy E. Hewett

  3. Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA

    Nathan D. Schilaty & Timothy E. Hewett

  4. Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA

    Edward R. Laskowski & Timothy E. Hewett

Authors
  1. Takashi Nagai
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  2. Nathan D. Schilaty
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  4. Timothy E. Hewett
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Contributions

TN and NS carried out all aspects of the study. EL and TE participated in the design and development of research aims. TN and TE were involved in interpretations of the results and discussion. All authors read and approved the final manuscript.

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Correspondence to Takashi Nagai.

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The authors do not have any conflict of interest to disclose.

Ethical approval

Institutional Review Board reviewed and approved the study (ID:15-009007).

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Written informed consent was obtained from all subjects.

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Nagai, T., Schilaty, N.D., Laskowski, E.R. et al. Hop tests can result in higher limb symmetry index values than isokinetic strength and leg press tests in patients following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 28, 816–822 (2020). https://doi.org/10.1007/s00167-019-05513-3

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