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Hamstrings Neuromuscular Function After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

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Abstract

Background

Hamstrings neuromuscular function is a crucial component of functional movement, and changes after anterior cruciate ligament (ACL) injury contribute to risk factors for secondary injury and long-term sequelae. To effectively treat muscular impairments, an accurate understanding of hamstrings neuromuscular function in patients with ACL reconstruction (ACLR) is needed.

Objective

A systematic review and meta-analysis were undertaken to describe and quantify hamstrings neuromuscular function in individuals with ACLR compared to controls.

Methods

We searched PubMed, Web of Science, SPORTDiscus, CINAHL, and EBSCOhost databases in October of 2020 for studies evaluating the difference between hamstrings electromyography (EMG) between individuals with ACLR and controls. Two independent reviewers assessed each paper for inclusion and quality. Means and standard deviations were extracted from each included study to allow random-effect size (ES) meta-analysis calculations for comparison of results.

Results

Thirty-four studies were included for final review. From these, 5 categories of neuromuscular outcomes were identified, and studies were grouped accordingly: (1) muscle activation levels (EMG amplitude), (2) co-activation, (3) onset timing, (4) electromechanical delay, and (5) time-to-peak activity. Moderate to strong evidence indicates that individuals with ACLR demonstrate higher hamstrings EMG amplitude (normalized to % maximum voluntary isometric contraction) and hamstrings-to-quadriceps co-activation during gait and stair ambulation compared to controls. In addition, there was moderate evidence of longer electromechanical delay during knee flexion and greater hamstrings-to-quadriceps co-activation during knee extension compared to controls.

Conclusions

Greater hamstrings EMG amplitude and co-activation during gait and ambulation tasks and longer electromechanical delay of the hamstrings in individuals with ACLR align with clinical impairments following ACLR and have implications for re-injury risk and long-term joint health, thus warranting attention in rehabilitation.

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Acknowledgements

The authors would like to acknowledge all participants who contributed to the original research reviewed in this work.

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Authors and Affiliations

  1. School of Exercise and Rehabilitation Sciences, College of Health and Human Services, The University of Toledo, 2801 W. Bancroft St., HH 2505E, Mail Stop 119, Toledo, OH, 43606, USA

    David A. Sherman & Grant E. Norte

  2. Department of Kinesiology, College of Agriculture, Health and Natural Resources, University of Connecticut, Storrs, CT, USA

    Neal R. Glaviano

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Correspondence to David A. Sherman.

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David Sherman, Neal Glaviano and Grant Norte declare that they have no conflicts of interest relevant to the content of this review.

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PRISMA.

Ethics approval

This is a systematic review. The University of Toledo Institutional Review Board for Biomedical Research has confirmed that no ethical approval is required.

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The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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All authors (DAS, NRG, and GEN) have contributed equally and demonstrated significant involvement in the planning and carrying out of this review and manuscript. Material preparation and data extraction were performed by DAS. Methodological quality review was performed by DAS and NRG. Data analysis was performed by DAS. The first draft of the manuscript was written by DAS and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Sherman, D.A., Glaviano, N.R. & Norte, G.E. Hamstrings Neuromuscular Function After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Sports Med 51, 1751–1769 (2021). https://doi.org/10.1007/s40279-021-01433-w

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  • DOI: https://doi.org/10.1007/s40279-021-01433-w

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