Arch Orthop Trauma Surg (2014) 134:1417–1428
DOI 10.1007/s00402-014-1992-x
ARTHROSCOPY AND SPORTS MEDICINE
Return to play following ACL reconstruction: a systematic review
about strength deficits
Wolf Petersen · Pouria Taheri · Phillip Forkel ·
Thore Zantop 
Received: 16 November 2013 / Published online: 5 August 2014
© Springer-Verlag Berlin Heidelberg 2014
Abstract  Keywords  Sports · ACL rupture · Hip · Hamstrings ·
Purpose  There is a lack of consensus regarding appropri-
ate criteria attesting patients’ unrestricted sports activities
after ACL reconstruction. Purpose of this study was to per-
form a systematic review about strength deficits to find out
if a strength test might be a return to play criterion.
Data source  Pubmed central, Google Scholar.
Study eligibility criteria  English language articles.
Interventions  Strength tests after ACL reconstruction
with autologous tendon grafts.
Methods  A systematic search for articles about muscle
strength after ACL reconstruction was performed.
Results  Forty-five articles could be identified. All arti-
cles identified reported strength deficits after ACL recon-
struction in comparison to control subjects. Some of these
deficits persisted up to 5 years after surgery. Knee flexor
strength is more impaired after ACL reconstruction with
hamstring grafts and quadriceps strength after BPTB ACL
reconstruction.
Conclusion  Strength deficits of hip, knee and ankle
muscles are reported after ACL reconstruction. Muscu-
lar strength test may be an important tool to determine
if an athlete can return to competitive sports after ACL
reconstruction.
W. Petersen (*) · P. Taheri · P. Forkel · T. Zantop 
Department of Trauma and Orthopaedic Surgery, Martin Luther
Hospital, Caspar Theyss Straße 27‑31, 14193 Berlin, Grunewald,
Germany
e-mail: w.petersen@mlk‑berlin.de
W. Petersen · P. Taheri · P. Forkel · T. Zantop 
Sporthopaedicum Straubing, Bahnhofsplatz 27, 94315 Straubing,
Germany
Quadriceps · Isokinetics
Introduction
The anterior cruciate ligament (ACL) plays an important
role on knee kinematics. It stabilizes the tibia against ante-
riorly directed and rotatory forces [22]. ACL deficiency
may lead to functional instability which may impair an ath-
lete to perform sports involving jumping, pivoting and cut-
ting maneuvers [34]. Functional instability may further lead
to secondary meniscus and cartilage injury [64]. Therefore,
for patients with functional instability surgical reconstruc-
tion of the ACL is recommended [67, 68]. For surgical
reconstruction, typically an autologous tendon graft is used
to replicate the native ACL. This surgical procedure is the
gold standard for the treatment of patients with objective
and subjective instability [67, 68].
Aim of ACL surgery in athletes is to allow a safe return
to preoperative activity level [5]. However, the reported
overall re-injury rates for the ACL vary between 0 and
19 % for the ipsilateral side and between 7 and 24 % for the
uninjured contralateral knee [9, 44, 68]. Possible factors for
re-injury are patient age (<21 years), high sportive activity,
and a too early return to demanding sports activity [65].
A systematic review has shown that there is a lack of
information and consensus on appropriate criteria about
the correct time of athletes returning to sports and return-
ing to their previous athletic activity [9]. For most authors
the time after surgery is the only criterion to decide if
a patient can return to sports [9]. In a recently published
survey among instructors of the Association for joint sur-
gery (AGA) approximately 63.5 % recommended a time
point later than 6 months for return to play after ACL
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1418
reconstruction [65]. The most frequent criteria to allow
return to play were a negative Lachman test (81.7 % posi-
tive answers) followed by free range of motion (78.4 %),
and a negative pivot shift (60.1 %).
Only 40.8 % of the participants reported to use a muscu-
lar strength analysis as criterion to allow a patient to unre-
stricted sportive activities [65]. However, it is well-known
that the muscles of the lower extremity play a major role
for the function of the knee joint. For example, hamstring
muscles contribute to stabilization in the ACL-injured knee
while the quadriceps force may contribute to ACL injury.
Co-activation of the hamstrings may assist in joint stability
by exerting an opposing torque to the anterior tibial transla-
tion induced by the quadriceps force. This opposing torque
stiffs the knee and attenuates the strain on ACL [62]. Two
previously systematic reviews focus on flexor and exten-
sor strength only and the results were contradictory. Dauty
et al. [19] stated that there was no difference between patel-
lar tendon graft or hamstring graft with regard to isokinetic
strength of knee flexors and extensor after more than 24
post-surgical months. Xergia et al. [80] found that patients
with an autologous patellar tendon graft showed a greater
deficit in extensor muscle strength and lower deficit in
flexor muscle strength compared with patients with ham-
string tendon graft. Both studies further focused on a fol-
low-up of 2 years after surgery.
However, not only knee extensor and flexor strength
might be relevant for successful rehabilitation after ACL
reconstruction. During the early phase of rehabilitation the
knee joint is protected and atrophy of other muscle groups
than knee flexors and extensors may occur as well. Weak-
ness of the hip abductor muscles for example may contrib-
ute to dynamic valgus which may predispose a patient to
ACL injury or re-injury [55].
The first aim of this systematic review was to extract
data regarding muscular deficiency after ACL reconstruc-
tion from the literature. The second aim was to find out if
muscular strength tests should be recommended as crite-
rion to allow an athlete to return to competitive sports. This
review should answer the following research questions:
1. Which muscles show a significant weakness after ACL
reconstruction?
2. How long will muscular deficiency persist after sur-
gery?
3. Are muscular strength deficits after ACL reconstruc-
tion graft-related?
We hypothesized that muscular strength deficits after
ACL reconstruction are graft-related, may persist of more
than 24 months after reconstruction of the ACL and that
strength deficits will not only involve knee muscles but also
hip and ankle muscles.
13
Arch Orthop Trauma Surg (2014) 134:1417–1428
Methods
We conducted a comprehensive literature search using
the Pubmed database and Google scholar to identify peer
reviewed articles about the muscle deficits after ACL
reconstruction according to the PRISMA statement.
For the systematic review different combinations of key-
words were utilized: (1) ACL reconstruction, (2) return to
sports, (3) strength (4) hamstrings, (5) quadriceps, (6) hip,
(7) ankle and (8) rehabilitation.
After identifying the articles, all references were
screened for additional relevant publications.
The following inclusion criteria were applied: Stud-
ies reporting muscular strength data of patients following
ACL reconstruction, strength test performed at a minimum
follow-up of 24 months, patients older than 16 years, and
English language reports. Both criteria should have been
satisfied for inclusion for this systematic review.
The abstracts of relevant articles were checked. In case
of a mismatch with one of the inclusion criteria the study
was excluded. In case of an eligible abstract, matching the
inclusion criteria, the full text article was studied. Articles
answering at least on one of the three questions:
1. Which muscles show a significant weakness after ACL
reconstruction?
2. How long will muscular deficiency persist after sur-
gery?
3. Are muscular strength deficits after ACL reconstruc-
tion graft-related?
Results
The search results are shown in Fig. 1. Out of these search
results 62 articles matching the inclusion criteria were iden-
tified. One article was excluded because it was published in
German. The majority of these articles found statistically
significant strength deficits of the operated leg after ACL
reconstruction.
Which muscles are involved?
The majority of articles revealed deficiencies of the quadri-
ceps muscles and the hamstrings after ACL reconstruction
[1–4, 6, 10–16, 26–29, 31–33, 35, 37–49, 51–53, 57, 59,
68, 70–80].
Six articles also revealed abnormalities of hip muscles.
These articles are summarized in Table 1. Four articles
with a follow-up between 6 and 24 months show postop-
erative reduction of hip extension strength [18, 26, 36, 74].
One study showed that the ratio of hip and knee exten-
sors was significantly greater after ACL reconstruction
Arch Orthop Trauma Surg (2014) 134:1417–1428 1419
Fig. 1  Flowchart showing the
literature review
with a significant negative correlation between the hip
extensor:knee extensor torque ratios and maximal anterior
tibia shear [62].
One study also found that plantar-flexor weakness was
greater preoperatively than postoperatively in the ACL-
injured limb (31.9 %) [74].
What is the time course of knee extensor and flexor
strength deficits after ACL injury and reconstruction?
Fifty-nine of these studies revealed strength deficits of knee
flexors and/or knee extensors after ACL injury.
Two studies reported on knee flexor and extensor
strength at a follow-up of 3 months after surgery [39, 43].
These authors found significant weakness for the knee
extensors and the knee flexors 3 months after reconstruc-
tion [39, 43].
The reported results 6 months postoperatively are con-
tradictory. One study found that after 6 months ACL-
injured participants had the same isokinetic knee extensor
and —flexor strength than control participants. Several
studies reported that the mean isokinetic strength deficit
for knee flexors or extensors decreased from surgery to
6 months postoperatively, with the highest measured deficit
occurring at 6 months postoperatively [3, 7, 15, 39, 53, 75,
79].
One study used a test battery of different strength tests to
show that nine out of ten patients after ACL reconstruction
exhibited abnormal leg power symmetry at 6 months after
surgery [58]. Heijne and Werner [33] examined 68 patients
with either patellar tendon graft (34 patients) or hamstring
graft (34 patients) and performed a randomized trial with
four subgroups: patellar tendon reconstruction or hamstring
tendon reconstruction with early start or late start of open
kinetic quadriceps exercises. These authors reported that,
only the early start patellar tendon group, reached preop-
erative values of quadriceps muscle torques at the 7 months
follow-up. In the early and late open kinetic hamstring
groups, significantly lower hamstring muscle torques at
the 7 months follow-up compared with preoperative values
were found.
De Jong et al. [20] showed an improvement of the flexor
and extensor strength deficits from 6 to 12 months post-
operatively but several studies revealed strength deficits at
the 1-year follow-up [14, 27, 35, 43, 73]. Karanikas et al.
[43] analyzed patients between 6 and 12 and between 12
and 24 months after ACL reconstruction and found lower
maximal joint moments for the knee extensors and the knee
flexors during both periods.
Several studies could identify strength deficits which
persisted 2 years or longer after ACL reconstruction [1, 6,
12, 20, 23, 29, 36, 38, 43, 46, 57, 69, 78]. Eitzen et al. [23]
showed that poor preoperative quadriceps strength is a pre-
dictor for postoperative strength deficits. Individuals with
preoperative quadriceps strength deficits of more than 20 %
had persistent significantly larger strength deficits 2 years
after surgery [23]. Roewer et al. [69] found that 2 years
after surgery, quadriceps strength in the involved limb
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13
Table 1   This table summarizes studies revealing hip muscle deficiancies after ACL reconstruction
Author
Thomas et al. [74]
Hiemstra et al. [36]
Dalton et al. [18]
Osternig et al. [62]
Karanikas et al. [43]
Geoghegan [26]
1420
Number of patients and control group Type of strength test and follow-up Results
30 Patients Isokinetic strength ACL-injured subjects had greater hip extensor (19.7 %) and
15 ACLR FU 6 months -adductor (16.3) weakness preoperatively than postoperatively,
15 controls regardless of limb, and greater postoperative hip adductor
strength (29.0 %) than control participants
30 Patients Isokinetic strength Hip extensors increase in strength after hamstring ACL recon-
15 ACLR FU 12 months struction, evening out normal side-to-side strength differences.
15 controls Hip adductor strength deficits of up to 43 % are demonstrated in
the ACL-reconstructed subjects compared with controls
30 Patients Isokinetic strength Reductions in hip abduction and extension strength after exercise
15 ACLR FU 24 months were noted in all participants; however, those with ACL recon-
15 controls structions displayed greater hip extensor strength loss after
aerobic exercise than did the control group
45 Patients Hip and knee joint moments and anterior tibia Hip:knee ratios were greater after ACLR (P < 0.01; P < 0.03).
15 ACL deficient subjects shear were recorded during lower extremity, Negative correlations between the hip extensor:knee extensor
15 ACLR variable resistance exercise torque ratios and maximal anterior tibia shear across all groups
15 controls FU 24 months The hip:knee extensor torque ratio increased with decreased ante-
rior tibia shear in all groups. The highest overall correlations
were found after ACLR
Anterior tibia shear declined with speed (P < 0.01) in all groups.
Hip:knee extensor torque ratio increased significantly with speed
(P < 0.001) for all groups at the 33 and 50 % resistances
35 Patients Isokinetic strength, FU The analysis of the muscle strength revealed lower (P < 0.05)
11 patients 3–6 months maximal joint moments for the knee extensors, the knee flexors
11 patients 6–12 months and the hip flexors of the injured limb during all the observed
13 patients 12–24 months post-surgery periods
40 Patients, 13 excluded Isokinetic strength Three months postoperatively there was a significant decrease
ST group 13 FU 3 and 12 months (P < 0.05) in the peak force of concentric hip extension in the
BPTB-group 14 4SHS group
There was no evidence that hip extension is weaker following
ACL reconstruction with 4SHS tendon autograft than ACL
reconstruction with BPTB autograft at 12 months postopera-
tively
Arch Orthop Trauma Surg (2014) 134:1417–1428
Arch Orthop Trauma Surg (2014) 134:1417–1428 1421

continued to improve. Natri et al. [57], however, revealed

flexor deficit was found in autograft patients than in allo-

reconstruction was observed, a significantly greater knee
3 (two-way ANOVA; group × side interaction P < 0.05,
that muscular deficits can persist longer than 2 years after

isometric knee flexor torque compared to Groups 2 and

Although significant knee flexion weakness after ACL

surgery. These authors examined patients after ACL recon-

Group 1 had decreased involved lower extremity peak

struction in the acute and chronic stage after an average
follow-up of 4 years. This study revealed that the exten-
sion strength deficit was significantly more prominent in
the chronic (18–20 %) than in the acute group (9–15 %)
[57]. Ageberg [1] showed that lower hamstring and quadri-
ceps muscle power may persist up to 3 years. Lautamies
et al. [51] found that even 5 years after ACL reconstruc-

graft patients (P < 0.001)

tion patients had weaker quadriceps and hamstring mus-

Tukey HSD = 0.008)
cle strength in the injured extremity compared with the
uninjured one. Keays et al. [44] showed that after a 6-year
follow-up there were no significant strength differences
between surgical and control groups, although a 6 %

Results
quadriceps deficit existed after patellar tendon grafting.

Were strength deficits after ACL reconstruction

Isokinetic in the sitting position (0°–90°), and in the prone

graft‑related?

Several articles examined if strength deficits after ACL

reconstruction are graft-related [2–4, 7, 10–12, 14–16, 20,
24, 27, 29, 33, 37, 40, 41, 44, 59, 50, 51, 53, 56, 70, 72, 73,
75, 77, 79].
Type of strength test and follow-up

Some of these articles could show that the graft choice

has an influence on strength deficits after surgery [12, 14,
Isometric knee flexor torque

16, 20, 27, 33, 37, 44, 59, 56, 70, 73]. Two studies found
greater strength deficit in autograft patients than in allograft position (60°–120°)
patients (Table 2).
Nineteen of these studies compared patients with a
patellar tendon autograft to patients with a hamstring ten-
FU 2 years

FU 2 years

don autograft [2, 3, 11, 12, 14, 15, 20, 27, 33, 35, 41, 44,
50, 51, 53, 75, 79]. Seven of these studies showed that
after 12–24 months after ACL reconstruction patients with
BPTB graft showed a greater deficit in extensor muscle
Group 3 20 Activity-level-matched control group
Table 2  This table summarizes studies of patients with allografts

strength and lower deficit in flexor muscle strength com-

pared with patients with HST and vice versa. Eight studies
were randomized controlled trials. These trials are summa-
Number patients and control group

rized in Table 3. Four of these trials could not show a statis-

Group 1 33 Hamstrings autografts

tically significant difference in flexor or extensor strength

Group 2 32 Achilles allografts
Group 1 20 ST/G autografts

in patients with either patellar tendon or hamstring tendon

Group 2 20 TA allografts

graft[11, 2, 15,41].
Two studies showed that patients had less flexor strength
deficit after allograft ACL reconstruction versus autologous
hamstring graft reconstruction [59, 50].
Landes et al. [50] 60 Patients

65 Patients

The results of studies that have examined flexor strength

deficits after semitendinosus tendon grafts alone and sem-
itendinosus/gracilis tendon grafts were inconsistent [4, 10,
40, 56, 70, 73]. These studies are summarized in Table 4.
Kim et al. [46]

Two studies found a difference in postoperative flexor

strength between patients with semitendinosus tendon
Author

autograft and semitendinosus/gracilis tendon autograft [70,

73]. Segawa et al. [70] showed that the peak flexion torque

13


Table 3  This table summarizes studies comparing muscle strength of patients with BPTBautograft and hamstring autograft
1422

Author Number patients and control group Type of strength test and follow-up Results

13
Aglietti [2] Quasi–RCT (alternating patients) Isokinetic 60°, 120°, 180° No difference in muscle strength recovery
FU 4, 12, 24 months
Anderson et al. [2] 45 Patients, compared with unoperated group Concentric and eccentric quadriceps and hamstring torque Improvement in all muscle functions in both the operated
Isokinetic dynamometer and unoperated legs during recovery period. Graft type
FU preoperatively, 6, 12 months had no effect on recovery
First 6 months, torque was restored to preoperative levels
Improve in all muscles and actions between 6 months and
1 year
Beard et al. [11] 60 Patients, 15 excluded Isokinetic 60° No significant difference between groups for any measure-
PT group 22 ST group 23 FU 6 and 12 months ment at 6 months and 1 year despite adequate study
power
Carter and Edinger [15] 120 Patients, 14 excluded Isokinetic at 180°/s and 300°/s No statistically significant differences in regard to knee
PT group 38 FU 6 months extension or flexion strength concerning the different
ST group 33 tissue sources
ST/G group 35 A majority of the patients had not achieved adequate
strength to participate in unlimited activities at 6 months
postoperatively
Aune et al. [7] 72 Patients Isokonetic 60°/s, 240°/s Hamstring tendon group showed better isokinetic knee
ST/G group 37 PT group 35 FU 6, 12, and 24 months extension strength than patellar tendon group after
6 months, but not after 12 and 24 months
Significant weakness in isokinetic knee flexion strength
among the hamstring tendon group
Feller and Webster [24] 20 Patients 60°/s, 240°/s Greater quadriceps peak torque deficits in the patellar
PT group 10 STG group: 10 FU 4, 8, 12, 24, and 36 months tendon group at 4 and 8 months but not thereafter
Hamstring tendon group, active flexion deficits were
greater from 8 to 24 months, and KT-1000 arthrometer
side-to-side differences in anterior knee laxity at 134 N
were greater
Jansson et al. [41] 89 Patients Isokinetic 60°/180°/s No statistically significant differences were seen with
PT group 43 STG group 46 respect to clinical and instrumented laxity testing, Inter-
national Knee Documentation Committee Score ratings,
isokinetic muscle torque measurements
Maletius et al. [53] 99 Patients Isokinetic, 60, 180, 300 The bone-patellar tendon-bone group had better flexion
PT group 46 ST/G group 53 FU 6, 12, and 24 months strength in the operated leg than in the nonoperated leg
(102 vs. 90 %, P = 0.0001), quadruple-strand semitendi-
nosus/gracilis group had better extension strength in the
operated leg than in the nonoperated leg (92 vs. 85 %,
P = 0.04)
Tow et al. [74] 68 Patients Isokinetic 60°/s, 240°/s Semitendinosus graft reconstruction was associated with
PT group 34 ST/G group 34 less donor-site morbidity and hamstring weakness
Arch Orthop Trauma Surg (2014) 134:1417–1428
 Arch Orthop Trauma Surg (2014) 134:1417–1428 1423

of the involved limb in internal rotation was decreased in

and 12 months isokinetic hamstrings strength was lower

nal stance was significantly smaller than that in the con-

Up till 6 months, the KT-1000 side-to-side difference was

significantly greater in the HS group (P < 0.05) and at 6
group and 23 % of subjects in the patellar tendon group
In contrast, the external knee extension moment at termi-

respect to quadriceps strength, functional scores, range

65 % of patients in the patellar tendon group and 29 %
Three-dimensional motion analysis and force plate system There were significant differences in the moments about

trol knees in 53 % of subjects in the hamstring tendon

the semitendinosus/gracilis group but not in the semiten-

No significant differences were noted at any stage with

significantly smaller than that in the control knees in
The external knee flexion moment at midstance was
dinosus group. Tashiro et al. [73] showed that at 70° or
more of flexion, the strength in the group with semitendi-
nosus and gracilis tendons was less than that in the group

of patients in the hamstring tendon group

with semitendinosus tendon alone at 18 months follow-up.
Four studies could detect no difference in flexor strength
the knee that related to graft type

between patients with semitendinosus tendon alone or both

semitendinosus and gracilis tendon autografts [4, 10, 40,
56].

of motion, or swelling
Discussion
(P < 0.05)

The results of this systematic review answer on all three

Results

questions.
to determine sagittal plane kinematics and kinetics of the

1. The majority of studies could demonstrate specific

muscular imbalances in the ACL-reconstructed leg
with control or the contralateral leg with the knee
lower limb during comfortable-speed walking

flexors and extensors involved. However, some recent

studies have also shown deficits of the hip muscles
after ACL reconstruction.
2. Muscular deficits are pronounced within the first
Type of strength test and follow-up

6 months after surgery, but they can persist up to

ST/G group: mean 9.3 months
FU PT group: mean 11 month

2 years and longer.

3. Muscular deficits after ACL reconstruction are graft-
FU 6w, 3, 6, 12 months
Isokinetic 60°/s, 240°/s

related. Extensor deficits are associated with patel-

lar tendon graft; flexion deficits are associated with
hamstring grafts. There is limited evidence with
inconsistent study results that there is a difference in
postoperative flexor strength between patients with
semitendinosus tendon autograft and semitendinosus/
gracilis tendon autograft.

These inconsistent results may be explained by meth-

odological differences between the studies such as power,
Number patients and control group

study design or differences in hamstring healing [25]. For

example Tadokoro et al. [72] found a regrowth of the sem-
itendinosus tendon in 22 of the 28 patients, and a regen-
eration of the gracilis tendon was observed in 13 patients.
In the evaluation of hamstring strength, the isometric peak
ST/G group 17
Ctrl group 17

torque was best restored in patients with semitendinosus

HS group 32
PT group 17

PT group 17
99 patients

49 patients

tendon regeneration.
Our results regarding extensor and flexor muscle deficits
are in accordance with two previous systematic reviews.
Both studies focus on the comparison between patients with
patellar tendon grafts versus hamstring tendon graft. Dauty
Witvrouw et al. [78]
Table 3  continued

Webster et al. [76]

et al. [19] identified 53 studies. These authors found that

ACL reconstruction with both grafts, patellar tendon and
hamstrings, showed a deficit either of knee extensor or knee
Author

flexors during several months after surgery. The flexor deficit

was more pronounced after hamstring graft harvesting; the

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1424

13
Table 4  This table summarizes studies that have examined flexor strength deficits after semitendinosus tendon grafts alone and semitendinosus/ gracilis tendon grafts
Author Number patients and control group Type of strength test and follow-up Results

Nakamura et al. [56] 74 Consecutive patients with hamstring ACL Evaluation of isokinetic muscle strength flexion torque In both the ST and ST/G groups, the knee flexor
reconstruction underwent at 2 years post-surgery at 90° of knee strength of the involved leg was less effectively
ST group 49 Flexion and peak flexion torque during isokinetic restored at 90° of knee flexion than at the angle at
ST/G group 25 testing which the peak torque was generated
FU 2 years No significant difference was seen in the side-to-side
ratio in either the peak flexion torque or the 90 degrees
flexion torque between the groups
The side-to-side ratio in mean maximum standing knee
flexion angle was significantly lower in the ST/G
group than in the ST group
Tashiro et al. [73] 90 Patients, 5 excluded Quadriceps and hamstring muscle strength was tested No significant difference in clinical results between the
ST Group49 before surgery and at FU 6, 12, and 18 months groups
ST/G Group 36 Neither group showed a significant decrease in isoki-
netic hamstring muscle strength
When subjects’ knees were at positions of 70° or more
of flexion, both isokinetic and isometric measurements
revealed a significant decrease in hamstring muscle
strength in both groups
The strength in the ST/G group was less than that in the
ST group at 18 months
Ardern et al. [4] 50 Patients Isokinetic hamstring strength at 60°, 180° peak torque No significant differences between the groups were
ST group 30 patients Torque produced at 60°, 90°, 105° of knee flexion found in any of the isometric or isokinetic strength
ST/G group 20 patients Isometric hamstring strength 30°, 90°,105° of knee measures or in the standing knee flexion angle
Individuals who had returned to regular sporting flexion No relation was found between the standing knee flex-
activity Standing knee flexion angle used to evaluate functional ion angle and the isometric hamstring strength results
hamstring strength recovery obtained at 105° of knee flexion (r2 = 0.034)
FU 32.5 months follow-up
Inagaki et al. [40] 110 Patients Isokinetic strength There were no significant differences between the two
ST Group 61 patients Knee stability and clinical outcome groups concerning the peak isokinetic torque of the
ST/G Group 59 patients FU 2 years quadriceps and the hamstrings
Barenius et al. [10] 20 Patients Low power subjective scores, function, strength and Results showed that the graft diameter was significantly
ST/G group 10 patients tibial rotation measured by gait analysis during a larger in the ST group
ST group 10 patients pivoting task There were no other differences between the groups for
FU 2 years any other outcome measure
Arch Orthop Trauma Surg (2014) 134:1417–1428
Arch Orthop Trauma Surg (2014) 134:1417–1428 1425
extensor deficit was more pronounced after patellar tendon
harvesting. Xergia et al. [80] included 14 studies in a system-
atic review. A meta-analysis of eight of the included stud-
ies showed a greater deficit in extensor muscle strength and
lower deficit in flexor muscle strength in patients after patel-
lar tendon ACL reconstruction compared with patients after
hamstring ACL reconstruction. These deficits were found up
to 2 years after ACL reconstruction [80].
Several factors explain strength deficits after ACL recon-
struction. Preoperative strength deficits [30, 81, 82] altera-
tion of length-tension relationship of the extensor mecha-
nism, attenuation of the y-loop function, and different
healing of hamstring tendons.
With the present systematic review we found inconsist-
ent results regarding the time course of muscular deficits.
Some authors reported that during the first 6–12 months,
strength was restored to preoperative levels [3, 76]. Oth-
ers showed muscular deficits may even persist longer than
2 years [1, 44, 51, 57]: 3 years (Ageberg), 4 years (Natri),
5 years and 6 years (Keays). In a study published by Har-
tigan et al [30]. some patients (non-copers) improved
strength during a 6-month-postoperative period and some
did not. Those who did not improve strength were more
likely to fail return to play criteria than patients who
improved strength. In this study, younger athletes who had
symmetrical quadriceps strength and greater knee flexor
moment were more likely to pass return to play criteria
[30]. The inconsistent results regarding the time course of
strength deficits may be explained by differences in the
rehabilitation protocols used in the different studies.
A recent systematic review has shown that a lack of
objective assessment methods exist in the published lit-
erature before release to unrestricted sports activities after
ACL reconstruction [9]. Restoration of muscle strength
is considered to be a critical factor for the outcome after
ACL reconstruction. The hamstrings are important agonist
to the ACL since they pull the tibia backwards. Therefore,
the deficit of flexor strength may be one factor that contrib-
utes to a re-rupture after ACL reconstruction. A systematic
review has shown that re-rupture rates after ACL recon-
struction vary between 0 and 19 % [9]. In studies compar-
ing re-rupture rates between hamstring and patellar tendon
ACL reconstruction, a tendency towards higher re-rupture
rates was observed in the hamstring groups (0 vs. 7 %,
[44]; 7 vs. 13 % [68]). These differences were not statis-
tically significant [44, 68]. However, it is well-known that
the hamstring tendons act as functional agonists to protect
the ACL. Therefore, we believe that the recovery of muscle
strength shall be a criterion for an athlete to return safely
back to unrestricted activities.
The most commonly used evaluation tool used in
the studies of this systematic review was isokinetic
dynamometry. Isokinetic means movement at a constant
speed. The most frequent speed used in the studies was
60°/s. A 10 % difference in muscle strength is considered
to be clinically relevant for patients after ACL reconstruc-
tion [49]. Therefore, we believe that isokinetic strength test
for knee flexors and extensors should be used to evaluate
if an athlete may safely return to competitive sports. In a
recently published survey among instructor of the AGA
only 41 % of the surgeons answered that strength tests
make a contribution to their decision about athletes return
to sports [65]. Other functional evaluation tools are hop
tests. Several authors have reported altered (and abnormal)
knee joint kinematics 4–12 months after ACL reconstruc-
tion during single-leg hop landings [21, 60].
The present systematic review revealed that some recent
studies reported deficits in hip strength after ACL recon-
struction [18, 26, 36, 43, 62, 74]. These findings may also
have relevance regarding the re-rupture rate. Well-known
neuromuscular risk factors for sustaining an ACL injury
are core and hip dysfunction, and increased knee abduction
moment (dynamic valgus) during impact on landing [54,
55]. Weak hip abductors and external rotators may cause an
internal rotation of the femur which may lead to a dynamic
valgus of the knee. All the studies identified for this sys-
tematic review used isokinetic tests for the evaluation of
hip muscle strength [18, 26, 36, 43, 62, 74]. However, to
analyze the dynamic valgus position, functional tests have
to be enforced.
To identify athletes at risk of severe knee injuries, drop
vertical jump tests have been described by several authors
[8, 34]. The athlete is instructed to drop off a box followed
by a maximum vertical jump. Athletes showing a nota-
ble valgus knee motion during landing should perform
neuromuscular training before sports participation which
includes training of hip abductors. This test was developed
to identify especially young female athletes who may be at
risk for an ACL rupture. This test could be part of a test
battery to evaluate athletes before a safe return to sports
can be recommended. Training which emphasizes the
“hip-knee-toe line” position when landing (avoid “kissing
knees”) could prevent future ACL injuries. Barber Westin
et al. [8] have shown that the video drop-jump test provides
a cost-effective general assessment of lower limb posi-
tion and depicts athletes who have poor control on landing
and acceleration into a vertical jump. Another test for the
assessment of functional valgus malalignment of the lower
extremity is the one-legged squat as described by Cross-
ley et al. [17]. Crossley et al. have shown that performance
on the single-leg squat task indicates hip abductor muscle
function. Further studies are needed to evaluate if the both
tests can be used as criterion for return to sports after ACL
reconstruction.
13

1426
Conclusion
In conclusion, this systematic review found strong evidence
for muscular flexor and extensor deficits after ACL recon-
struction which may be graft-related. Therefore, isokinetic
examination of flexor and extensor strength should be used
as one criterion to decide if an athlete can be allowed to
return to unrestricted sportive activities. The rehabilita-
tion protocol after ACL reconstruction should focus on the
used graft and aim on negotiation of graft-related-muscle
weakness. Deficits in hip muscle strength may occur. Train-
ing on hip muscle strength may help to prevent a dynamic
valgus during landing positions. This might influence the
re-rupture rate after ACL reconstruction. Further research
is necessary to find out which tests are able to evaluate hip
strength (functional or isokinetic) and if they are suitable to
be used as a return to sports criterion.
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