Abstract
Background
Anterior cruciate ligament reconstruction (ACLR) may not restore lower limb biomechanics during single-limb landings.
Objectives
Our objective was to identify and evaluate differences in lower limb biomechanics during high-demand single-limb landings between the ACLR limb and the contralateral limb and healthy control participants.
Methods
A systematic review of the literature was conducted using six electronic databases searched until April 2017 for published peer-reviewed studies that investigated lower limb biomechanics on the ACLR limb compared with either the contralateral limb or those of control participants. Meta-analysis with standardized mean differences (SMD) were performed for peak angles and moments (hip, knee and ankle joints) in the sagittal plane during single-limb landing tasks.
Results
A total of 35 studies met inclusion criteria. Four different single-leg landing tasks were identified: forward hop (n = 24 studies), landing from a height (n = 9 studies), vertical hop (n = 4 studies), and diagonal leap (n = 1 study). A reduced peak knee flexion angle was found in the ACLR limb compared with the contralateral limb during a forward hop landing task (SMD − 0.39; 95% confidence interval [CI] − 0.59 to − 0.18) and compared with a control group (SMD between − 1.01 and − 0.45) for all three reported single-leg landing tasks: forward hop, landing from a height, and diagonal leap. Similarly, a reduced peak knee internal extensor moment was found in the ACLR limb compared with the contralateral limb for all three reported landing tasks: forward hop, landing from a height, vertical hop (SMD between − 1.43 and − 0.53), and in two of three landing tasks when compared with a control group (SMD between − 1.2 and − 0.52). No significant differences in peak flexion (hip and ankle) angle or peak (hip and ankle) internal extensor moment were found in the ACLR limb compared with both the contralateral limb and a control group.
Conclusions
Participants performed single-limb landings on the ACLR limb with reductions in peak sagittal knee kinematics as well as peak joint moments compared with both the contralateral limb and a control group. Stiffer single-leg landings potentially expose the knee joint to higher forces, which may increase risk of injury. Clinical testing after ACLR surgery should explore movement quality as well as performance of functional tasks.
Level of evidence
Case–control, IV
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References
Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE. Strength asymmetry and landing mechanics at return to sport after anterior cruciate ligament reconstruction. Med Sci Sports Exerc. 2015;47(7):1426–34. https://doi.org/10.1249/mss.0000000000000560.
Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(1):216–24.
Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five percent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543–52. https://doi.org/10.1136/bjsports-2013-0933981.
Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACLR reconstruction and return to sport. Clin J Sport Med. 2012;22(2):116–21.
Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42(7):1567–73.
Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction. a systematic review and meta-analysis. Am J Sports Med. 2016;44(7):1861–76.
Morgan MD, Salmon LJ, Waller A, Roe JP, Pinczewski LA. Fifteen-year survival of endoscopic anterior cruciate ligament reconstruction in patients aged 18 years and younger. Am J Sports Med. 2016;44:384–92.
Webster KE, Feller JA. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44:2827–32.
Webster KE, Feller JA, Leigh WB, Richmond AK. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(3):641–7.
Wright RW, Gill CS, Chen L, Brophy RH, Matava MJ, Smith MV, Mall NA. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg. 2012;94:531–6.
Abrams GD, Harris JD, Gupta AK, McCormick FM, Bush-Joseph CA, Verma NN, et al. Functional performance testing after anterior cruciate ligament reconstruction: a systematic review. Orthop J Sports Med. 2014;2(1):2325967113518305. https://doi.org/10.1177/2325967113518305.
Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2012;42(9):750–9.
Dingenen B, Gokeler A. Optimization of the return-to-sport paradigm after anterior cruciate ligament reconstruction: a critical step back to move forward. Sports Med. 2017;47(8):1487–500. https://doi.org/10.1007/s40279-017-0674-6.
Wren TAL, Mueske NM, Brophy CH, Pace JL, Katzel MJ, Edison BR, et al. Hop distance symmetry does not indicate normal landing biomechanics in adolescent athletes with recent anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2018. https://doi.org/10.2519/jospt.2018.7817.
Hart HF, Culvenor AG, Collins NJ, Ackland DC, Cowan SM, Machotka Z, Crossley KM. Knee kinematics and joint moments during gait following anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Br J Sports Med. 2016;50:597–612.
Hart JM, Ko J-WK, Konold T, Pietrosimione B. Sagittal plane knee joint moments following anterior cruciate ligament injury and reconstruction: a systematic review. Clin Biomech. 2010;25:277–83.
Kaur M, Ribeiro DC, Theis J-C, Webster KE, Sole G. Movement patterns of the knee during gait following ACL reconstruction: a systematic review and meta-analysis. Sports Med. 2016;46:1869–95.
Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2010;38(10):1968–78. https://doi.org/10.1177/0363546510376053.
Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999;34(2):86–92.
Krosshaug T, Nakamae A, Boden BP, Engebretsen L, Smith G, Slauterbeck JR, Hewett TE, Bahr A. Mechanisms of anterior cruciate ligament injury in basketball video analysis of 39 cases. Am J Sports Med. 2007;35(3):359–67.
Olsen O-E, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball a systematic video analysis. Am J Sports Med. 2004;32(4):1002–12.
Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23(6):573–8.
Prapavessis H, McNair PJ. Effects of instruction in jumping technique and experience jumping on ground reaction forces. J Orthop Sports Phys Ther. 1999;29(6):352–6.
Schmitz RJ, Kulas AS, Perrin DH, Riemann BL, Schultz SJ. Sex differences in lower extremity biomechanics during single leg landings. Clin Biomech. 2007;22(6):681–8.
Heebner NR, Rafferty DM, Wohleber MF, Simonson AJ, Lovalekar M, Reinert A, Sell TC. Landing kinematics and kinetics at the knee during different landing tasks. J Athl Train. 2017;52(12):1101–8.
Antolic V, Strazar K, Pompe B, Pavlovcic V, Vengust R, Stanic U, Jeraj J. Increased muscle stiffness after anterior cruciate ligament reconstruction–memory on injury? Int Orthop. 1999;23(5):268–70.
Engelen-van Melick N, van Cingel RE, van Tienen TG, Nijhuis-van der Sanden MW. Functional performance 2-9 years after ACL reconstruction: cross-sectional comparison between athletes with bone-patellar tendon-bone, semitendinosus/gracilis and healthy controls. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1412–23. https://doi.org/10.1007/s00167-015-3801-7.
Oberländer KD, Brüggemann GP, Höher J, Karamanidis K. Knee mechanics during landing in anterior cruciate ligament patients: a longitudinal study from pre-to 12 months post-reconstruction. Clin Biomech. 2014;29(5):512–7.
Tengman E, Grip H, Stensdotter AK, Häger CK. Anterior cruciate ligament injury about 20 years post-treatment: a kinematic analysis of one-leg hop. Scand J Med Sci Sports. 2015;25(6):818–27.
Trigsted SM, Post EG, Bell DR. Landing mechanics during single hop for distance in females following anterior cruciate ligament reconstruction compared to healthy controls. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1395–402. https://doi.org/10.1007/s00167-015-3658-9.
Vairo GL, Myers JB, Sell TC, Fu FH, Harner CD, Lephart SM. Neuromuscular and biomechanical landing performance subsequent to ipsilateral semitendinosus and gracilis autograft anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16(1):2–14.
Webster KE, Feller JA. Tibial rotation in anterior cruciate ligament reconstructed knees during single limb hop and drop landings. Clin Biomech. 2012;27(5):475–9.
Webster KE, Santamaria LJ, McClelland JA, Feller JA. Effect of fatigue on landing biomechanics after anterior cruciate ligament reconstruction surgery. Med Sci Sports Exerc. 2012;44(5):910–6.
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52:377–84.
Hébert-Losier K, Pini A, Vantini S, Strandberg J, Abramowicz K, Schelin L, Häger CK. One-leg hop kinematics 20 years following anterior cruciate ligament rupture: data revisited using functional data analysis. Clin Biomech. 2015;30(10):1153–61.
Webster KE, Kinmont CJ, Payne R, Feller JA. Biomechanical differences in landing with and without shoe wear after anterior cruciate ligament reconstruction. Clin Biomech. 2004;19(9):978–81.
Oberländer KD, Brueggemann GP, Hoeher J, Karamanidis K. Altered landing mechanics in ACL-reconstructed patients. Med Sci Sports Exerc. 2013;45(3):506–13.
Orishimo KF, Kremenic IJ, Mullaney MJ, McHugh MP, Nicholas SJ. Adaptations in single-leg hop biomechanics following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18(11):1587–93.
Pozzi F, Di Stasi S, Zeni JA, Barrios JA. Single-limb drop landing biomechanics in active individuals with and without a history of anterior cruciate ligament reconstruction: a total support analysis. Clin Biomech. 2017;43:28–33.
Furukawa TA, Barbui C, Cipriani A, Brambilla P, Watanabe N. Imputing missing standard deviations in meta-analyses can provide accurate results. J Clin Epidemiol. 2006;59(1):7–10.
Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC. 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. 2015;43(11):2727–37.
Palmieri-Smith RM, Lepley LK. 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. 2015;43(7):1662–9.
Xergia SA, Pappas E, Georgoulis AD. Association of the single-limb hop test with isokinetic, kinematic, and kinetic asymmetries in patients after anterior cruciate ligament reconstruction. Sports Health. 2015;7(3):217–23.
Friedrich JO, Adhikari NKJ, Beyene J. The ratio of means method as an alternative to means differences for analyzing continuous outcome variables in meta-analysis: a simulation study. BMC Med Res Methodol. 2008;8:32.
Hunter JE, Schmidt FL. Fixed effects vs random effects meta-analysis models: implications for cumulative research knowledge. Int J Select Assess. 2000;8(4):275–92.
von Porat A, Henriksson M, Holmström E, Thorstensson CA, Mattsson L, Roos EM. Knee kinematics and kinetics during gait, step and hop in males with a 16 years old ACL injury compared with matched controls. Knee Surg Sports Traumatol Arthrosc. 2006;14(6):546–54.
Webster KA, Gribble PA. Time to stabilization of anterior cruciate ligament-reconstructed versus healthy knees in national collegiate athletic association division i female athletes. J Athl Train. 2010;45(6):580–5.
Colby SM, Hintermeister RA, Torry MR, Steadman JR. Lower limb stability with ACL impairment. J Orthop Sports Phys Ther. 1999;29(8):444–54.
Deneweth JM, Bey MJ, McLean SG, Lock TR, Kolowich PA, Tashman S. Tibiofemoral joint kinematics of the anterior cruciate ligament-reconstructed knee during a single-legged hop landing. Am J Sports Med. 2010;38(9):1820–8.
Delahunt E, Prendiville A, Sweeney L, Chawke M, Kelleher J, Patterson M, Murphy K. Hip and knee joint kinematics during a diagonal jump landing in anterior cruciate ligament reconstructed females. J Electromyogr Kinesiol. 2012;22(4):598–606.
Gokeler A, Hof AL, Arnold MP, Dijkstra PU, Postema K, Otten E. Abnormal landing strategies after ACL reconstruction. Scand J Med Sci Sports. 2010. https://doi.org/10.1111/j.1600-0838.2008.00873.x.
Webster K, Gonzalez-Adrio R, Feller J. Dynamic joint loading following hamstring and patellar tendon anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(1):15–21.
Xergia SA, Pappas E, Zampeli F, Georgiou S, Georgoulis AD. Asymmetries in functional hop tests, lower extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2013;43(3):154–62.
Roos PE, Button K, Sparkes V, van Deursen RW. Altered biomechanical strategies and medio-lateral control of the knee represent incomplete recovery of individuals with injury during single leg hop. J Biomech. 2014;47(3):675–80.
Lepley LK, Wojtys EM, Palmieri-Smith RM. Combination of eccentric exercise and neuromuscular electrical stimulation to improve biomechanical limb symmetry after anterior cruciate ligament reconstruction. Clin Biomech. 2015;30(7):738–47.
Ernst GP, Saliba E, Diduch DR, Hurwitz SR, Ball DW. Lower-extremity compensations following anterior cruciate ligament reconstruction. Phys Ther. 2000;80(3):251–60.
Button K, Roos PE, van Deursen RW. Activity progression for anterior cruciate ligament injured individuals. Clin Biomech. 2014;29(2):206–12.
Letchford R, Button K, Adamson P, Roos PE, Sparkes V, Robert W, van Deursen M. A novel clinical approach for assessing hop landing strategies: a 2D telescopic inverted pendulum (TIP) model. Knee Surg Sports Traumatol Arthrosc. 2016;24(1):279–86.
Podraza JT, White SC. Effect of knee flexion angle on ground reaction forces, knee moments and muscle co-contraction during an impact-like deceleration landing: implications for the non-contact mechanism of ACL injury. Knee. 2010;17(4):291–5. https://doi.org/10.1016/j.knee.2010.02.013.
Meyer EG, Haut RC. Excessive compression of the human tibio-femoral joint causes ACL rupture. J Biomech. 2005;38:2311–6.
Hewett TE, Lindenfeld TN, Riccobene JB, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. Am J Sports Med. 1999;27(6):699–706.
Sinsurin K, Vachalathiti R, Jalayondeja W, Limroongreungrat W. Different sagittal angles and moments of lower extremity joints during single-leg jump landing among various directions in basketball and volleyball athletes. J Phys Ther Sci. 2013;25:1109–13.
Shimokochi Y, Lee SY, Shultz SJ, Schmitz RJ. The relationships among sagittal-plane lower extremity moments: implications for landing strategy in anterior cruciate ligament injury prevention. J Athl Train. 2009;44(1):33–8.
Lewek M, Rudolph K, Axe M, Snyder-Mackler L. The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech. 2002;17(1):56–63.
Mendiguchia J, Ford KR, Quatman CE, Alentorn-Geli E, Hewett TE. Sex differences in proximal control of the knee joint. Sports Med. 2011;41(7):541–57.
Verrell GM, Slavotinek JP, Barnes PG, Fon GT, Spriggins AJ. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. Br J Sports Med. 2001;35:435–40.
Ford KR, Myer GD, Hewett TE. Reliability of landing 3D motion analysis: implications for longitudinal analysis. Med Sci Sports Exerc. 2007;39(11):2021–8.
Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492–501.
Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther. 2006;36(6):385–402.
Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med. 2009;37(7):1434–43. https://doi.org/10.1177/0363546509338827.
Baumgart C, Schubert M, Hoppe MW, Gokeler A, Freiwald J. Do ground reaction forces during unilateral and bilateral movements exhibit compensation strategies following ACL reconstruction? Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1385–94. https://doi.org/10.1007/s00167-015-3623-7.
Bryant AL, Newton RU, Steele J. Successful feed-forward strategies following ACL injury and reconstruction. J Electromyogr Kinesiol. 2009;19(5):988–97.
Hofbauer M, Thorhauer ED, Abebe E, Bey M, Tashman S. Altered tibiofemoral kinematics in the affected knee and compensatory changes in the contralateral knee after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(11):2715–21.
McGrath TM, Waddington G, Scarvell JM, et al. An ecological study of anterior cruciate ligament reconstruction, part 2: functional performance tests correlate with return-to-sport outcomes. Orthop J Sports Med. 2017;5(2):2325967116688443.
Nyland J, Wera J, Klein S, Caborn DN. Lower extremity neuromuscular compensations during instrumented single leg hop testing 2–10 years following ACL reconstruction. Knee. 2014;21(6):1191–7.
Rudroff T. Functional capability is enhanced with semitendinosus than patellar tendon ACL repair. Med Sci Sports Exerc. 2003;35(9):1486–92.
Webster KE, Wotherspoon S, Feller JA, McClelland JA. The effect of anterior cruciate ligament graft orientation on rotational knee kinematics. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):2113–20.
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This work was supported by an Australian Government Research Training Program Scholarship.
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Peta Johnston, Jodie McClelland and Kate Webster have no conflict of interest.
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Johnston, P.T., McClelland, J.A. & Webster, K.E. Lower Limb Biomechanics During Single-Leg Landings Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Sports Med 48, 2103–2126 (2018). https://doi.org/10.1007/s40279-018-0942-0
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DOI: https://doi.org/10.1007/s40279-018-0942-0