Skip to main content
SpringerLink
Log in

Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To compare patient reported outcomes and functional knee recovery following anterior cruciate ligament (ACL) reconstruction using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft.

Methods

Thirty-five QT patients (age 20; range 15–34 years) participated in this study and were matched for gender, age and pre-injury activity level to 70 HT (age 20; range 15–32 years) patients. The following assessments were performed at 6 and 12 months post-operatively; standardized patient-reported outcome measures (IKDC, KOOS-QOL, ACL-RSI, Marx activity, anterior knee pain), knee range of motion (passive and active), anterior knee laxity, hop tests (single and triple crossover hop for distance), and isokinetic strength of the knee extensors and flexors. All dependent variables were analysed using a two-way mixed ANOVA model, with within (Time; 6 and 12 months) and between-subject (Graft; QT and HT) factors.

Results

Patient reported outcome measures and hop performance improved between 6 and 12 months (p < 0.001), however no significant differences in either patient-reported outcomes or hop performance were found between the two grafts. Isokinetic strength testing showed both groups improved their peak knee extensor strength in the operated limb between 6 and 12 months (p < 0.001), but the QT group had significantly lower knee extensor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.001) and 180 deg/s (p < 0.01). In contrast, the QT group had significantly greater knee flexor strength symmetry at both time points compared to HT at 60 deg/s (p < 0.01) and 180 deg/s (p = 0.01), but knee flexor strength limb symmetry did not significantly improve over time in either group.

Conclusion

Recovery of knee function following either QT or HT ACL reconstruction continues between 6 and 12 months after surgery. However, knee extensor strength deficits in the QT group and knee flexor strength deficits in the HT persisted at 12 months. This may have implications for decisions regarding return to sport.

Level of evidence

III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

ACL:

Anterior cruciate ligament

ACL-RSI:

Anterior cruciate ligament-return to sport after injury scale

HT:

Hamstring tendon

IKDC:

International knee documentation committee-subjective knee evaluation form

KOOS-QOL:

Knee injury and osteoarthritis outcome score-knee-related quality of life subscale

LSI:

Limb symmetry index

Marx:

Marx activity rating scale

PEP:

Prevent injury and enhance performance

PT:

Patellar tendon

QT:

Quadriceps tendon

References

  1. Abrams GD, Harris JD, Gupta AK, McCormick FM, Bush-Joseph CA, Verma NN, Cole BJ et al (2014) Functional performance testing after anterior cruciate ligament reconstruction: A systematic review. Orthop J Sports Med 2(1):2325967113518305

    PubMed  PubMed Central  Google Scholar 

  2. Austin PC (2010) Statistical criteria for selecting the optimal number of untreated subjects matched to each treated subject when using many-to-one matching on the propensity score. Am J Epidemiol 171(9):1092–1097

    Google Scholar 

  3. 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(1):149–154

    PubMed  Google Scholar 

  4. Batty LM, Feller JA, Hartwig T, Devitt BM, Webster KE (2019) Single-leg squat performance and its relationship to extensor mechanism strength after anterior cruciate ligament reconstruction. Am J Sports Med 47(14):3423–3428

    PubMed  Google Scholar 

  5. Belk JW, Kraeutler MJ, Marshall HA, Goodrich JA, McCarty EC (2018) Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction: a systematic review of comparative studies with minimum 2-year follow-up. Arthroscopy 34(5):1699–1707

    PubMed  Google Scholar 

  6. Bizzini M, Dvorak J (2015) FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide—a narrative review. Br J Sports Med 49:577–579

    PubMed  Google Scholar 

  7. Burgi CR, Peters S, Ardern CL, Magill JR, Gomez CD, Sylvain J et al (2019) Which criteria are used to clear patients to return to sport after primary ACL reconstruction? A scoping review. Br J Sports Med 53(18):1154–1161

    PubMed  Google Scholar 

  8. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM (2011) Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken) 63 Suppl:S208–28

  9. Cristiani R, Mikkelsen C, Forssblad M, Engström B, Stålman A (2019) Only one patient out of five achieves symmetrical knee function 6 months after primary anterior cruciate ligament reconstruction. Knee Surg Sports TraumatolArthrosc 27:3461–3470

    Google Scholar 

  10. Cristiani R, Mikkelsen C, Wange P, Olsson D, Stålman A, Engström B (2020) Autograft type affects muscle strength and hop performance after ACL reconstruction. A randomised controlled trial comparing patellar tendon and hamstring tendon autografts with standard or accelerated rehabilitation. Knee Surg Sports TraumatolArthrosc. https://doi.org/10.1007/s00167-020-06334-5

    Article  Google Scholar 

  11. Curran MT, Lepley LK, Palmieri-Smith RM (2018) Continued improvements in quadriceps strength and biomechanical symmetry of the knee after postoperative anterior cruciate ligament reconstruction rehabilitation: is it time to reconsider the 6-month return-to-activity criteria? J Athl Train 53(6):535–544

    PubMed  PubMed Central  Google Scholar 

  12. Davies WT, Myer GD, Read PJ (2020) Is it time we better understood the tests we are using for return to sport decision making following ACL reconstruction? A critical review of the hop tests. Sports Med 50(3):485–495

    PubMed  Google Scholar 

  13. Dunn WR, Spindler KP, MOON Consortium (2010) Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a multicenter orthopaedic outcomes network (MOON) ACLR cohort study. Am J Sports Med 38(10):2040–2050

    Google Scholar 

  14. Ebert JR, Webster KE, Edwards PK, Joss BK, D’Alessandro P, Janes G et al (2019) Current perspectives of Australian therapists on rehabilitation and return to sport after anterior cruciate ligament reconstruction: a survey. Phys Ther Sport 35:139–145

    PubMed  Google Scholar 

  15. Fischer F, Fink C, Herbst E, Hoser C, Hepperger C, Blank C et al (2018) Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction. Knee Surg Sports TraumatolArthrosc 26(2):418–425

    Google Scholar 

  16. 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(13):804–808

    PubMed  Google Scholar 

  17. 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(1):15

    PubMed  PubMed Central  Google Scholar 

  18. Hurley ET, Calvo-Gurry M, Withers D, Farrington SK, Moran R, Moran CJ (2018) Quadriceps tendon autograft in anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 34(5):1690–1698

    PubMed  Google Scholar 

  19. Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29(5):600–613

    CAS  PubMed  Google Scholar 

  20. 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 TraumatolArthrosc 26(2):426–433

    Google Scholar 

  21. Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC (2015) Young athletes with quadriceps femoris strength asymmetry at return to sport after anterior cruciate ligament reconstruction demonstrate asymmetric single-leg drop-landing mechanics. Am J Sports Med 43(11):2727–2737

    PubMed  Google Scholar 

  22. Johnston PT, McClelland JA, Feller JA, Webster KE (2020) Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: systematic review and meta-analysis. Knee Surg Sports TraumatolArthrosc. https://doi.org/10.1007/s00167-020-06311-y

    Article  Google Scholar 

  23. Kotsifaki A, Korakakis V, Whiteley R, Van Rossom S, Jonkers I (2020) Measuring only hop distance during single leg hop testing is insufficient to detect deficits in knee function after ACL reconstruction: a systematic review and meta-analysis. Br J Sports Med 54(3):139–153

    PubMed  Google Scholar 

  24. Krishnan C, Williams GN (2011) Factors explaining chronic knee extensor strength deficits after ACL reconstruction. J Orthop Res 29(5):633–640

    PubMed  PubMed Central  Google Scholar 

  25. 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(15):946–951

    PubMed  Google Scholar 

  26. Lepley LK (2015) Deficits in quadriceps strength and patient-oriented outcomes at return to activity after ACL reconstruction: a review of the current literature. Sports Health 7(3):231–238

    PubMed  PubMed Central  Google Scholar 

  27. Lewallen S, Courtright P (1998) Epidemiology in practice: case–control studies. Commun Eye Health 11(28):57–58

    CAS  Google Scholar 

  28. Lind M, Nielsen TG, Soerensen OG, Mygind-Klavsen B, Faunø P (2020) Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial. Br J Sports Med 54(3):183–187

    PubMed  Google Scholar 

  29. Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF (2001) Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 29(2):213–218

    CAS  PubMed  Google Scholar 

  30. Meta F, Lizzio VA, Jildeh TR, Makhni EC (2017) Which patient reported outcomes to collect after anterior cruciate ligament reconstruction. Ann Joint 2(5):21

    Google Scholar 

  31. Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E (2019) Anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring-tendon autografts. Am J Sports Med 47(14):3531–3540

    PubMed  Google Scholar 

  32. Myer GD, Martin L Jr, Ford KR, Paterno MV, Schmitt LC, Heidt RS Jr et al (2012) No association of time from surgery with functional deficits in athletes after anterior cruciate ligament reconstruction: evidence for objective return-to-sport criteria. Am J Sports Med 40(10):2256–2263

    PubMed  PubMed Central  Google Scholar 

  33. Nagai T, Schilaty ND, Laskowski ER, Hewett TE (2020) 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 TraumatolArthrosc 28(3):816–822

    Google Scholar 

  34. Nagelli CV, Hewett TE (2017) Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? BiolFunct Consider Sports Med 47(2):221–232

    Google Scholar 

  35. Noyes FR, Barber Westin SD (2012) Anterior cruciate ligament injury prevention training in female athletes: a systematic review of injury reduction and results of athletic performance tests. Sports Health 4(1):36–46

    PubMed  PubMed Central  Google Scholar 

  36. 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(5):513–518

    CAS  PubMed  Google Scholar 

  37. Palmieri-Smith RM, Lepley LK (2015) Quadriceps strength asymmetry after anterior cruciate ligament reconstruction alters knee joint biomechanics and functional performance at time of return to activity. Am J Sports Med 43(7):1662–1669

    PubMed  PubMed Central  Google Scholar 

  38. Petersen W, Taheri P, Forkel P, Zantop T (2014) Return to play following ACL reconstruction: a systematic review about strength deficits. Arch Orthop Trauma Surg 134(10):1417–1428

    PubMed  Google Scholar 

  39. 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(3):337–349

    PubMed  Google Scholar 

  40. Roos EM, Lohmander LS (2003) The knee injury and osteoarthritis outcome score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes 1:64

    PubMed  PubMed Central  Google Scholar 

  41. Runer A, Wierer G, Herbst E, Hepperger C, Herbort M, Gföller P et al (2018) There is no difference between quadriceps- and hamstring tendon autografts in primary anterior cruciate ligament reconstruction: a 2-year patient-reported outcome study. Knee Surg Sports TraumatolArthrosc 26(2):605–614

    Google Scholar 

  42. Sachs RA, Daniel DM, Stone ML, Garfein RF (1989) Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 17(6):760–765

    CAS  PubMed  Google Scholar 

  43. Sanders TL, MaraditKremers H, Bryan AJ, Larson DR, Dahm DL, Levy BA et al (2016) Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med 44(6):1502–1507

    PubMed  Google Scholar 

  44. Thomeé R, Neeter C, Gustavsson A, Thomeé P, Augustsson J, Eriksson B et al (2012) Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports TraumatolArthrosc 20(6):1143–1151

    Google Scholar 

  45. Webster KE, Feller JA (2019) Expectations for return to preinjury sport before and after anterior cruciate ligament reconstruction. Am J Sports Med 47(3):578–583

    PubMed  Google Scholar 

  46. Webster KE, Feller JA, Lambros C (2008) Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport 9(1):9–15

    PubMed  Google Scholar 

  47. Welling W, Benjaminse A, Seil R, Lemmink K, Gokeler A (2018) Altered movement during single leg hop test after ACL reconstruction: implications to incorporate 2-D video movement analysis for hop tests. Knee Surg Sports TraumatolArthrosc 26(10):3012–3019

    Google Scholar 

  48. Whitley E, Ball J (2002) Statistics review 4: sample size calculations. Crit Care 6(4):335–341

    PubMed  PubMed Central  Google Scholar 

  49. Xergia SA, McClelland JA, Kvist J, Vasiliadis HS, Georgoulis AD (2011) The influence of graft choice on isokinetic muscle strength 4–24 months after anterior cruciate ligament reconstruction. Knee Surg Sports TraumatolArthrosc 19(5):768–780

    Google Scholar 

  50. Zbrojkiewicz D, Vertullo C, Grayson JE (2018) Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. Med J Aust 208(8):354–358

    PubMed  Google Scholar 

Download references

Acknowledgements

This work was supported by an Australian Government Research Training Program Scholarship. Data collection for this study was completed by the research team at OrthoSport Victoria.

Funding

The authors received no specific funding for this work.

Author information

Authors and Affiliations

  1. School of Allied Health, Human Services and Sport, College of Science, Health and Engineering, La Trobe University, Melbourne, VIC, 3086, Australia

    Peta T. Johnston, Jodie A. McClelland & Kate E. Webster

  2. OrthoSport Victoria Research Unit, Melbourne, Australia

    Julian A. Feller

Authors
  1. Peta T. Johnston
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Julian A. Feller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jodie A. McClelland
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kate E. Webster
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KW, JF, & JM conceived of the study. PJ participated in the data analysis and performed statistical analysis and drafted the manuscript. All authors participated in critically revising the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kate E. Webster.

Ethics declarations

Conflict of interest

The authors listed on this manuscript certify none declared.

Ethical approval

Ethics approval was obtained from the relevant institutions (La Trobe University: HEC19003; Epworth Healthcare: HREC57012).

Informed consent

All participants were recruited from an existing longitudinal ACL reconstruction study, in which all participants had provided informed consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Johnston, P.T., Feller, J.A., McClelland, J.A. et al. Knee strength deficits following anterior cruciate ligament reconstruction differ between quadriceps and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 30, 1300–1310 (2022). https://doi.org/10.1007/s00167-021-06565-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-021-06565-0

Keywords

Search

Navigation