Knee muscle activity during gait in patients with anterior cruciate ligament injury: a systematic review of electromyographic studies

  • Sanaz Shanbehzadeh
  • Mohammad Ali Mohseni Bandpei
  • Fatemeh Ehsani



This review compared knee muscle activity between ACL-deficient (ACLD) patients and healthy controls during gait, to find out whether the available electromyography (EMG) studies support Quadriceps (Q-ceps) inhibition or hamstring facilitation during gait in ACLD patients.


A systematic review was conducted to retrieve the EMG studies of knee muscles during gait in ACLD patients. Cochrane library, PubMed, Medline, Ovid, CINAHL and Science Direct databases were searched entries from 1995 through October 2014 using the terms “anterior cruciate ligament” OR “ACL”, “electromyography” Or “EMG” “gait” Or “walking”. Articles that assessed subjects with ACL rupture that used surface EMG to assess the knee muscle activity were included. The quality of the included papers was assessed using the Critical Appraisal Skills Programme tool for observational studies.


In total, 13 studies met the inclusion criteria. Seven studies consistently found no significant difference in magnitude of activity or timing of Q-ceps muscle between the chronic ACLD patients and control subjects. Two studies on acute ACLD patients and three studies on ACLD patients with unstable knee found the significantly reduced Q-ceps activity compared to control subjects. Six studies showed the significantly greater hamstring activity, and three studies found prolonged duration of activity in ACLD patients compared to the control subjects.


This review highlighted that the results of the studies are in favour of increased hamstring muscular activity. However, decreased Q-ceps activation exists in the acute stage and in ACLD patients that experience knee instability (non-copers).

Level of evidence



Electromyography Anterior cruciate ligament injury Gait 


  1. 1.
    Alkjaer TSE, Jørgensen U, Dyhre-Poulsen P (2003) Evaluation of the walking pattern in two types of patients with anterior cruciate ligament deficiency: copers and non-copers. Eur J Appl Physiol 89:301–308CrossRefPubMedGoogle Scholar
  2. 2.
    Beard D, Soundarapandian R, O’Connor J, Dodd C (1996) Gait and electromyographic analysis of anterior cruciate ligament deficient subjects. Gait Posture 4:83–88CrossRefGoogle Scholar
  3. 3.
    Beard DJ, Kyberd PJ, O’Connor JJ, Fergusson CM, Dodd CA (1994) Reflex hamstring contraction latency in anterior cruciate ligament deficiency. J Orthop Res 12:219–228CrossRefPubMedGoogle Scholar
  4. 4.
    Benoit D, Lamontagne M, Cerulli G, Liti A (2003) The clinical significance of electromyography normalisation techniques in subjects with anterior cruciate ligament injury during treadmill walking. Gait Posture 18:56–63CrossRefPubMedGoogle Scholar
  5. 5.
    Berchuck M, Andriacchi TP, Bach BR, Reider B (1990) Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg 72:871–877CrossRefPubMedGoogle Scholar
  6. 6.
    Boerboom AL, Hof AL, Halbertsma JP, Raaij JJ, Schenk W, Diercks RL, Horn JR (2001) Atypical hamstrings electromyographic activity as a compensatory mechanism in anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc 9:211–216CrossRefPubMedGoogle Scholar
  7. 7.
    Bulgheroni P, Bulgheroni M, Andrini L, Guffanti P, Castelli C (1997) Walking in anterior cruciate ligament injuries. Knee 4:159–165CrossRefGoogle Scholar
  8. 8.
    Bulgheroni P, Bulgheroni M, Andrini L, Guffanti P, Giughello A (1997) Gait patterns after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 5:14–21CrossRefPubMedGoogle Scholar
  9. 9.
    Burden A, Trew M, Baltzopoulos V (2003) Normalisation of gait EMGs: a re-examination. J Electromyogr Kines 13:519–532CrossRefGoogle Scholar
  10. 10.
    CASP (Critical Skills Appraisal Programme) (2007) Learning & Development Public Health Resource Unit, Oxford, UK. Accessed 1 May 2007
  11. 11.
    Ciccotti MG, Kerlan RK, Perry J, Pink M (1994) An electromyographic analysis of the knee during functional activities II. The anterior cruciate ligament-deficient and-reconstructed profiles. Am J Sports Med 22:651–658CrossRefPubMedGoogle Scholar
  12. 12.
    Cohen J (2013) Statistical power analysis for the behavioral sciences. Academic press, LondonGoogle Scholar
  13. 13.
    Ferber R, Osternig LR, Woollacott MH, Wasielewski NJ, Lee J-H (2002) Gait mechanics in chronic ACL deficiency and subsequent repair. Clin Biomech 17:274–285CrossRefGoogle Scholar
  14. 14.
    Fleming BC, Renstrom PA, Ohlen G, Johnson RG, Peura GD, Beynnon BD, Badger GJ (2001) The gastrocnemius muscle is an antagonist of the anterior cruciate ligament. J Orthop Res 19:1178–1184CrossRefPubMedGoogle Scholar
  15. 15.
    French HP, Dunleavy M, Cusack T (2010) Activation levels of gluteus medius during therapeutic exercise as measured with electromyography: a structured review. Phys Ther Rev 15:92–105CrossRefGoogle Scholar
  16. 16.
    Gao B, Zheng NN (2010) Alterations in three-dimensional joint kinematics of anterior cruciate ligament-deficient and-reconstructed knees during walking. Clin Biomech 25:222–229CrossRefGoogle Scholar
  17. 17.
    Gardinier ES, Manal K, Buchanan TS, Snyder-Mackler L (2012) Gait and neuromuscular asymmetries after acute ACL rupture. Med Sci Sports Exerc 44:1490CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Gardinier ES, Manal K, Buchanan TS, Snyder-Mackler L (2014) Clinically-relevant measures associated with altered contact forces in patients with anterior cruciate ligament deficiency. Clin Biomech 29:531–536CrossRefGoogle Scholar
  19. 19.
    Gardinier ES, Manal K, Buchanan TS, Snyder-Mackler L (2013) Altered loading in the injured knee after ACL rupture. J Orthop Res 31:458–464CrossRefPubMedGoogle Scholar
  20. 20.
    Hubley-Kozey C, Deluzio K, Dunbar M (2008) Muscle co-activation patterns during walking in those with severe knee osteoarthritis. Clin Biomech 23:71–80CrossRefGoogle Scholar
  21. 21.
    Hurd WJ, Snyder-Mackler L (2007) Knee instability after acute ACL rupture affects movement patterns during the mid-stance phase of gait. J Orthop Res 25:1369–1377CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Knoll Z, Kiss RM, Kocsis L (2004) Gait adaptation in ACL deficient patients before and after anterior cruciate ligament reconstruction surgery. J Electromyogr Kines 14:287–294CrossRefGoogle Scholar
  23. 23.
    Knoll Z, Kocsis L, Kiss RM (2004) Gait patterns before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 12:7–14CrossRefPubMedGoogle Scholar
  24. 24.
    Kuster M, Sakurai S, Wood G (1995) The anterior cruciate ligament-deficient knee: compensatory mechanisms during downhill walking. Knee 2:105–111CrossRefGoogle Scholar
  25. 25.
    Kvist J, Gillquist J (2001) Anterior positioning of tibia during motion after anterior cruciate ligament injury. Med Sci Sports Exerc 33:1063–1072CrossRefPubMedGoogle Scholar
  26. 26.
    Lewek M, Rudolph K, Axe M, Snyder-Mackler L (2002) The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech 17:56–63CrossRefGoogle Scholar
  27. 27.
    Lewek MD, Rudolph KS, Snyder-Mackler L (2004) Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis. J Orthop Res 22:110–115CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Lindström M, Felländer-Tsai L, Wredmark T, Henriksson M (2010) Adaptations of gait and muscle activation in chronic ACL deficiency. Knee Surg Sports Traumatol Arthrosc 18:106–114CrossRefPubMedGoogle Scholar
  29. 29.
    Liu W, Maitland M (2000) The effect of hamstring muscle compensation for anterior laxity in the ACL-deficient knee during gait. J Biomech 33:871–879CrossRefPubMedGoogle Scholar
  30. 30.
    Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG (2009) Epidemiology of anterior cruciate ligament reconstruction. J Bone Joint Surg 91:2321–2328CrossRefPubMedGoogle Scholar
  31. 31.
    Majewski M, Susanne H, Klaus S (2006) Epidemiology of athletic knee injuries: a 10-year study. Knee 13:184–188CrossRefPubMedGoogle Scholar
  32. 32.
    Merlin T, Weston A, Tooher R (2009) Extending an evidence hierarchy to include topics other than treatment: revising the Australian ‘levels of evidence’. BMC Med Res Methodol 9:34CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151:264–269CrossRefPubMedGoogle Scholar
  34. 34.
    Reed-Jones RJ, Vallis LA (2008) Kinematics and muscular responses to a ramp descent in the ACL deficient knee. Knee 15:117–124CrossRefPubMedGoogle Scholar
  35. 35.
    Roberts CS, Rash GS, Honaker JT, Wachowiak MP, Shaw JC (1999) A deficient anterior cruciate ligament does not lead to quadriceps avoidance gait. Gait Posture 10:189–199CrossRefPubMedGoogle Scholar
  36. 36.
    Rudolph KS, Axe MJ, Buchanan TS, Scholz JP, Snyder-Mackler L (2001) Dynamic stability in the anterior cruciate ligament deficient knee. Knee Surg Sports Traumatol Arthrosc 9:62–71CrossRefPubMedGoogle Scholar
  37. 37.
    Rudolph KS, Eastlack ME, Axe MJ, Snyder-Mackler L (1998) 1998 Basmajian Student Award Paper: movement patterns after anterior cruciate ligament injury: a comparison of patients who compensate well for the injury and those who require operative stabilization. J Electromyogr Kines 8:349–362CrossRefGoogle Scholar
  38. 38.
    Shiavi R, Bugle H, Limbird T (1986) Electromyographic gait assessment, part 1: adult EMG profiles and walking speed. J Rehabil Res Dev 24:13–23Google Scholar
  39. 39.
    Smith TO, Bowyer D, Dixon J, Stephenson R, Chester R, Donell ST (2009) Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. Physiother Theory Pract 25:69–98CrossRefPubMedGoogle Scholar
  40. 40.
    Smith TO, Dixon J, Bowyer D, Davies L, Donell ST (2008) EMG activity of vastus medialis and vastus lateralis with patellar instability: a systematic review. Physiother Theory Pract 13:405–414Google Scholar
  41. 41.
    Torry MR, Decker MJ, Ellis HB, Shelburne KB, Sterett WI, Steadman JR (2004) Mechanisms of compensating for anterior cruciate ligament deficiency during gait. Med Sci Sports Exerc 36:1403–1412CrossRefPubMedGoogle Scholar
  42. 42.
    Torry MR, Decker MJ, Viola RW, O’Connor DD, Steadman JR (2000) Intra-articular knee joint effusion induces quadriceps avoidance gait patterns. Clin Biomech 15:147–159CrossRefGoogle Scholar
  43. 43.
    Wojtys EM, Huston LJ (1994) Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. Am J Sports Med 22:89–104CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Sanaz Shanbehzadeh
    • 1
  • Mohammad Ali Mohseni Bandpei
    • 2
    • 3
  • Fatemeh Ehsani
    • 1
    • 4
  1. 1.Department of PhysiotherapyUniversity of Social Welfare and Rehabilitation SciencesTehranIran
  2. 2.University Institute of Physical Therapy, Faculty of Allied Health SciencesUniversity of LahoreLahorePakistan
  3. 3.Iranian Research Centre on Aging, Department of PhysiotherapyUniversity of Social Welfare and Rehabilitation SciencesTehranIran
  4. 4.Neuromuscular Rehabilitation Research Centre, Rehabilitation FacultySemnan University of Medical SciencesSemnanIran

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