Strength Asymmetry and Landing Mechanics at Return to Sport after ACL Reconstruction

There are inadequate evidence-based quadriceps femoris muscle (QF) strength guidelines for return to sport following anterior cruciate ligament (ACL) reconstruction. This study examined the impact of QF strength asymmetry on knee landing biomechanics at the time of return to sport following ACL reconstruction. Seventy-seven individuals (17.4 years) at the time of return to sport following primary ACL reconstruction (ACLR group) and 47 uninjured control individuals (17.0 years) (CTRL group) participated. QF strength was assessed and Quadriceps Index calculated (QI = [involved strength/uninvolved strength]*100%). The ACLR group was sub-divided based on QI: High Quadriceps (HQ, QI≥90%) and Low-Quadriceps (LQ, QI<85%). Knee kinematic and kinetic variables were collected during a drop vertical jump maneuver. Limb symmetry during landing, and discrete variables were compared among the groups with multivariate analysis of variance and linear regression analyses. The LQ group exhibited worse asymmetry in all kinetic and ground reaction force variables compared to the HQ and CTRL groups, including reduced involved limb peak knee external flexion moments (p<.001), reduced involved limb (p=.003) and increased uninvolved limb (p=.005) peak vertical ground reaction forces, and higher uninvolved limb peak loading rates (p.05). In the ACLR group, QF strength estimated limb symmetry during landing after controlling for graft type, meniscus injury, knee pain and symptoms.

Individuals post-ACL reconstruction with weaker QF demonstrated altered landing patterns wheen they returned to sport. Conversely, those with nearly symmetrical QF strength exhibit landing patterns similar to uninjured individuals. Consideration of an objective QF strength measure may assist in clinical decision-making to optimize sports participation following ACL reconstruction.

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