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Time, graft, sex, geographic location, and isokinetic speed influence the degree of quadriceps weakness after anterior cruciate ligament reconstruction: a systematic review and meta-analysis



Although quadriceps weakness after ACL reconstruction (ACLR) is well documented, the magnitude of reported weakness varies considerably. Such variation raises the possibility that certain patients may be more susceptible to quadriceps weakness after ACLR. This meta-analysis identified factors explaining between-study variability in quadriceps weakness post-ACLR.


Studies between 2010 and 2020 were screened for the following criteria: human subjects, unilateral ACLR, and strength reported both for the ACLR leg and the uninjured or healthy-control leg. 122 studies met the criteria, resulting in 303 and 152 Cohen’s d effect sizes (ESs) comparing ACLR legs to uninjured legs (a total of 4135 ACLR subjects) and to healthy controls (a total of 1,507 ACLR subjects vs. 1-193 healthy controls), respectively. Factors (time, graft, sex, activity, mass/height, geographic area, concomitant injury, and type of strength testing) that may affect study ES were examined.


Meta-regressions indicated an association between time post-ACLR and study ESs (P < 0.001) and predicted full recovery (ES = 0) to occur at 54–59 months post-ACLR. When compared to uninjured legs, patients with patellar tendon autografts had greater deficits than studies using hamstring tendon autografts (P = 0.023). When compared to uninjured legs, studies including only males reported greater deficits than studies combining males and females (P = 0.045); whereas when compared to healthy controls, studies combining males and females reported greater deficits than studies with males (P = 0.013). When compared to controls, studies from USA reported greater deficits than studies from Europe (P = 0.003). Increased isokinetic-testing speed was associated with smaller deficits (P ≤ 0.025). Less than 25% of patients achieved a between-limb symmetry in quadriceps strength > 90% between 6 and 12 months post-ACLR.


Time post-surgery, graft, sex, geographic location, and isokinetic speed influenced the magnitude of post-ACLR quadriceps weakness. Patients with patellar tendon autografts demonstrated greater between-limb asymmetry in quadriceps strength, while female strength deficits were underestimated to a greater extent. A slower isokinetic speed provided a more sensitive assessment of quadriceps strength post-ACLR. The overwhelming majority of patients were returning to sport with significantly impaired quadriceps strength.

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LCT, CMJ, KAH, and GLW contributed to conception and design of the study. LCT, CMJ, KAH, and DFC contributed to collection and analysis of the data, while all authors were invovled with data interpretation. LCT, JMP, and MAL drafted the article, and all authors read and approved the final manuscript.

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Correspondence to Liang-Ching Tsai.

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Tsai, LC., Jeanfreau, C.M., Hamblin, K.A. et al. Time, graft, sex, geographic location, and isokinetic speed influence the degree of quadriceps weakness after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 30, 3367–3376 (2022).

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  • ACLR
  • Knee extensors
  • Muscle weakness
  • Meta-analysis