Published online: 2020-06-26
Review
Is Pre-operative Quadriceps Strength a Predictive Factor for the
Outcomes of Anterior Cruciate Ligament Reconstructions
Authors
Jihong Qiu1, Xin He1, Sai-Chuen Fu1, 2 , Michael Tim-Yun Ong1, Hio Teng Leong1 , Patrick Shu-Hang Yung1, 2
Affiliations
1 Department of Orthopaedics and Traumatology, Faculty
of Medicine, The Chinese University of Hong Kong, Hong
Kong SAR, China
2 Luis Che Woo Institute of Innovative Medicine, Faculty of
Medicine, The Chinese University of Hong Kong, Hong
Kong SAR, China
Key words
anterior cruciate ligament, quadriceps strength, systematic
review
accepted 28.02.2020
Bibliography
DOI https://doi.org/10.1055/a-1144-3111
Published online: 2020
Int J Sports Med
© Georg Thieme Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Patrick Shu-Hang Yung
Room 74029,5/F, Lui Che Woo Clinical Science Building,
Prince of Wales Hospital
Shatin, NT
Hong Kong
Tel.: + 852 35052083, Fax: + 852 2646 3020
patrickyung@cuhk.edu.hk
Introduction
Anterior cruciate ligament (ACL) injuries are the most commonly
reported knee injuries in orthopaedics and sports medicine with
about 300 000 anterior cruciate ligament reconstructions (ACLR)
performed in USA annually [1, 2]. ACLR is performed in order to re-
store normal knee stability in patients with ACL injury. The ultimate
goal of the treatment is to ensure patients’ safe return to pre-inju-
ry level of sports [3], however, about 35 % patients fail to return to
their pre-injury level of sports despite successful surgery and reha-
bilitation [4].
Although at present there is no consensus, most return to sports
criteria includes quadriceps strength, functional outcomes and psy-
chological readiness [5]. Quadriceps weakness is an important fac-
tor that hinders patients from returning to sports because it is sig-
Qiu J et al. Is Pre-operative Quadriceps Strength … Int J Sports Med
Thieme
Abstr act
Persistent quadriceps weakness prevents patients from return-
ing to sports after ACL reconstruction. Pre-operative quadri-
ceps strength was indicated as an important factor for the
outcomes of ACL reconstruction. However, the existing evi-
dence is controversial. Therefore, this systematic review was
conducted to summarize and evaluate the relationship be-
tween pre-operative quadriceps strength and the outcomes
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following ACL reconstruction, and to summarize the predictive
value of pre-operative quadriceps strength for satisfactory
post-operative outcomes. Pubmed, WOS, Embase, CINAHL and
SportDiscus were searched to identify eligible studies accord-
ing to PRISMA guidelines. Relevant data was extracted regard-
ing quadriceps strength assessment methods, pre-operative
quadriceps strength, participants treatment protocols, post-
operative outcomes, follow-up time points and the relevant
results of each individual study. Twelve cohort studies (Cole-
man methodology score: 62 ± 10.4; from 44–78) with 1773
participants included. Follow-up period ranged from 3 months
to 2 years. Moderate evidence supports the positive association
between pre-operative quadriceps strength and post-operative
quadriceps strength; weak evidence supports the positive as-
sociation between pre-operative quadriceps strength and post-
operative functional outcomes. By now, there is no consensus
on the predictive value of pre-operative quadriceps strength
for achieving satisfactory quadriceps strength after ACLR. To
conclude, pre-operative quadriceps strength should be taken
into consideration when predict patient recovery of ACLR.
nificantly associated with poor functional outcomes after ACLR [6].
Asymmetrical quadriceps strength has been demonstrated to cor-
relate with adaptive movement characteristics such as stiff landing
with significant knee valgus [7, 8]. Some patients still experience
‘giving way’ after ACL reconstruction, which can be partly due to
quadriceps weakness [9]. Poor quadriceps strength is also correlat-
ed with the level of kinesiophobia that aggravates the abnormal
movement patterns [10]. Furthermore, asymmetry of quadriceps
strength is also an essential risk factor for the higher re-injury rate of
ACL reconstructed patients when compared with normal population
[5].
Pre-operative quadriceps strength has been proposed to be a
significant predictor for the outcomes of ACLR [11–13]. It has been
reported that severe quadriceps strength deficit pre-operatively is
 Review
a factor for the persistent quadriceps weakness after reconstruc-
tion [12, 14]. Quadriceps weakness is a common phenomenon be-
fore ACLR due to injury-induced neuromuscular dysfunction and
decreased activity level during the period from injury to surgery
[15, 16]. Hence, previous studies recommended adding pre-oper-
ative exercises to reduce neuromuscular dysfunction and increase
quadriceps strength before surgery to achieve better functional
outcomes following ACLR [16–18]. However, different studies used
different exercise protocols and reported different results in terms
of improving post-operative quadriceps strength and functional
outcomes, and it is still unknown whether increasing pre-operative
quadriceps strength is an effective way to improve quadriceps
strength and functional outcomes following ACLR. Therefore, in
order to determine if quadriceps strength needs to be measured
prior to surgery in clinic, it is imperative to investigate whether pre-
operative quadriceps strength is associated with post-operative
quadriceps strength, and functional outcomes.
Hence, the primary goal of this systematic review is to summa-
rize and evaluate the associations between pre-operative quadri-
ceps strength and post-operative quadriceps strength and the
functional outcomes of ACLR. The secondary goal is to summarize
the predictive values of pre-operative quadriceps strength for sat-
isfactory post-operative quadriceps strength.
Materials and Methods
This systematic review was conducted and presented according to
the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines [19], and it met the ethical standard
of Harriss et al. [20].
Search strategy
An electronic database search of Pubmed; CINAHL, SportDiscus
(via EBSCOhost), Web of Science, and Embase was undertaken from
inception to December 2019. Keywords that were used in the
search include: (1) anterior cruciate ligament OR ACL; (2) preoper-
ative OR pre-operative OR prior to operation OR prior to recon-
struction OR prior to surgery OR predict * ; (3) quadriceps OR knee
extensors; (4) strength OR force OR power; (5) weakness OR defi-
cit OR deficiency OR loss OR failure. Terms (1), (2), (3), (4), (5)
searching results were combined with “AND” boolean operator.
The searches were limited to human study, English and there was
no limitation on the publication date of the studies.
The first 2 authors (Q-JH and HX) of this study undertook the
literature search and the screening process independently. After
removing the duplicates, the titles, abstracts and full texts were
screened for eligibility. The bibliographies of the included studies
were also screened. In all of the above process, any disagreements
between the 2 authors were resolved by discussion with the third
author (F-SC).
Eligibility criteria
Articles were considered eligible for inclusion if they met the fol-
lowing criteria:
(1) Participants had primary unilateral ACL rupture and recon-
struction.
(2) Pre-operative quadriceps strength was reported.
Thieme
(3) Followed up the participants to post-operation, and report-
ed quadriceps strength and functional outcomes including patients
reported outcomes, functional tests and activity level.
(4) Study design was randomized control study, cohort study,
case control study or cross sectional study.
(5) Study report was published in English and full text articles
prior to December 2019.
Articles were excluded if they were:
Case studies, reviews, editorials, commentaries, and opinion-
based papers.
Quality assessment
A modified version of Coleman Methodology Score was used to as-
sess the quality of eligible studies. The original Coleman score was
utilized as an orthopaedic quality assessment tool for patellar tendi-
nopathy outcomes studies, and the score had 2 subsections, includ-
ing part A and part B to evaluate bias of treatment outcomes and as-
sessment outcomes respectively [21]. Modifications of item 2 and
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item 5 in Part A of the original version were made to make the score
more relevant to the topic of this systematic review. For items 2, the
threshold of follow-up duration changed from ‘12 and 24 months’
into ‘ 6 months and 12 months’ to make it more closely matched with
clinical follow-up of ACL reconstructed patients. Item 5 was changed
from ‘ Diagnostic certainty’ to ‘ Description of participant’s demo-
graphics’ to evaluate the control of confounders in each individual
study. The total score of individual study is between 0–100, and high-
er score means higher quality. For the purpose of this review, studies
with scores > 80 were defined as high quality, 60–80 were defined as
moderate quality, and < 60 were defined as low quality. The overview
of the score is shown in (▶Table 1S, Supplemental File I).The first
(Q-JH) and second (HX) authors independently assessed each includ-
ed study. Any disagreements were solved by discussion between the
first and second authors, and if there were disagreements remained
unresolved, there were further discussions with the third author (F-
SC) of this review.
Data extraction and synthesis
All data was extracted from the included studies by the first author
(Q-JH). For the primary goal, data extracted covered participant
demographics, graft type used for reconstruction, post-operative
rehabilitation scheme; strength measurement methods; pre-op-
erative strength; quadriceps strength and functional outcomes of
reconstruction; follow-up time points and relevant results of each
individual study. For the secondary goal, the predictive value of
quadriceps strength prior to surgery was also extracted.
Results
Literature search
A total of 426 studies were identified using the search strategy and
4 additional studies were identified from bibliography lists of eligi-
ble studies. After removing 218 duplicates, 212 studies were ex-
cluded by screening of titles and abstracts. The full texts of 21 stud-
ies were retrieved, with 12 studies meeting all of the inclusion cri-
teria. The procedure of literature search is shown in ▶Fig. 1.
Qiu J et al. Is Pre-operative Quadriceps Strength … Int J Sports Med
 Records identified through
database searching (n = 426)
Pubmed (n = 65)
Web of Science (n = 129)

Identification
Additional records identified
Embase (n = 78)
CINAHL (n = 105) through cited references
SportDiscus (n = 49) (n = 4)

Duplicates excluded
Remaining records after duplicates removed
(n = 218)
(n = 212)
Screening

Records excluded: (n = 191)

Remaining records after Reivew/case report/commentary/
screening titles and abstract editorial/conference abstract (n = 27)
(n = 21) irrelevant topic (n = 164)
not published in English (n = 1)

Full-text articles excluded, with reasons:

(n = 8)
Eligibility

Reviews (n = 1)
Full-text articles assessed Conference abstract without full text
for eligibility (n = 1)

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(n = 21) Not report pre-operative quadriceps
strength (n = 4)
Could not get the access to the full text
(n = 1)
Full text published in French (n = 1)
Included

Studies included in
qualitative synthesis
(n = 12)

▶Fig. 1 The Flowchart of Literature Search

Quality assessment strength was measured by different dynamometers during maximum

The score of quality assessment ranged from 44–78, with a mean
of 62 ± 10.4. There were nine studies of moderate quality [11–
14, 22–26] and 3 studies were low quality [27–39]. The scores of
each individual study are shown in ▶Table 1.
Study characteristics
Patient demographics of the included studies are shown in ▶Table 2.
Eleven of the 12 included studies were prospective cohort studies ex-
cept for the study by de Jong SN et al. which was a retrospective co-
hort study [28]. A total of 1773 participants were included in this re-
view and the majority of the participants were male (n = 1102,
63.6 %). The age of the participants ranged from14–50 years old. The
reported time from injury to surgery ranged from 0.5–15 years. Of
the included studies, 6 studies recorded pre-injury activity level of
participants. Among the 12 studies, participants from 6 studies were
reconstructed with bone patellar tendon bone (BPTB) autograft
[11, 12, 25–27, 29], 4 studies with hamstring autograft or allograft
[13, 14, 22, 23], and another 2 studies reconstructed with either BPTB
or hamstring autograft [24, 28]. Nine studies provided their own post-
operative rehabilitation protocols with the duration ranging from 7
weeks to 1 year. All of the reported rehabilitation protocols included
muscle strengthening exercises, proprioception and balance training
as well as plyometric training [11–14, 22–29]. The treatment proto-
cols of each individual study are listed in ▶Table 3. Quadriceps
voluntary isometric contractions or isokinetic contractions. Five stud-
ies assessed quadriceps strength through maximum voluntary iso-
metric test (MVIC) [11, 13, 22, 26, 29], and the other 7 studies as-
sessed through isokinetic test at different speeds [12, 14, 23–
25, 27, 28]. For the units of quadriceps strength, 8 studies
[12, 13, 23–26, 28, 29] used quadriceps strength symmetry index
(QSI) which was calculated as the quadriceps peak torque on the in-
jured side divided by the quadriceps peak torque on the uninjured
side, three studies [11, 22, 27] used normalized strength (peak
torque/body weight) and one study used both QSI and normalized
strength [14]. The duration of follow-up ranged from 3 months to 2
years. Outcomes of ACL reconstruction included quadriceps strength,
quadriceps atrophy; single leg hop performance, patient’s reported
outcomes and level of sporting activities.
Due to the limited number of eligible studies, and the discrep-
ancies of strength measurement methods, units of strength and
follow-up duration among individual studies, it was not meaning-
ful to conduct a meta-analysis. Results of each individual study are
presented in ▶Table 4.
Post-operative quadriceps strength
Nine studies investigated the association between pre-operative
and post-operative quadriceps strength. Of which, 8 studies (5
studies are moderate quality; 3 studies are low quality) demon-

Qiu J et al. Is Pre-operative Quadriceps Strength … Int J Sports Med

 Review Thieme

▶Table 1 Modified Coleman Score of each individual study.

Study Part A Part B

1 2 3 4 5 6 7 Total 1 2 3 Total Total
Lepley LK et al. [11] 7 2 10 10 0 3 0 32 10 8 15 33 65
Eitzen I et al. [12] 7 5 10 10 0 3 0 35 10 11 15 36 71
Logerstedt D et al. [13] 10 2 0 10 5 3 0 30 10 11 15 36 66
Shibata Y et al. [14] 10 2 10 10 5 5 0 42 10 11 13 34 76
Zargi TG et al. [22] 4 0 10 10 0 5 0 29 7 11 15 33 62
Ueda Y et al. [23] 10 2 10 10 5 5 0 42 10 11 15 36 78
Heijne A et al. [24] 10 2 0 10 0 3 0 22 10 15 15 40 62
Shelbourne KD et al. [25] 10 5 0 10 0 3 0 28 7 11 15 33 61
Mariani PP et al. [26] 7 0 10 10 5 3 0 35 10 11 8 29 64
Hallagin C et al. [27] 4 0 10 10 0 3 0 27 10 11 5 26 53
de Jong SN et al. [28] 10 2 0 0 5 3 0 20 10 6 8 24 44
McHugh MP et al. [29] 4 2 10 10 0 3 0 29 7 11 0 18 47
Average score 31 31 62

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▶Table 2 Demographics of participants.

Study Demographics of Participants

No. Sex (M/F) Age Pre-injury Concomitant injuries (No.) Time from injury to
activity level surgery
Lepley LK et al. [11] 54 23/31 14–38 N Meniscus (21) 0.5–10.4 months
Eitzen I et al. [12] 60 39/21 15–40 N Meniscus (30) 7 weeks–3 years
Logerstedt D et al. [13] 83 55/28 26.8 ± 11.2 Level 1–2 Meniscus (30) 1.1–39.9 weeks
Shibata Y et al. [14] 386 205/181 23.7 ± 9.5 7.1 ± 1.8 Meniscal (159) 11.1 ± 35 months
(Tegner)
Zargi TG et al. [22] 25 20/5 18–45 N Meniscus (13) > 6 months
Ueda Y et al. [23] 193 106/87 21.0 ± 6.8 ≥ 7 (Tegner) Cartilage (15) 6.8 ± 14.2 months
Meniscus (85)
Heijne A et al. [24] 64 39/25 16–50 N Meniscus; Cartilage; MCL < 6 months: 26
injury (39) 6–12 months: 20 >
13 months: 18
Shelbourne KD et al. [25] 540 348/192 26.4 ± N N N
8.5/23.6 ± 9.1
Mariani PP et al. [26] 59 59/0 18–33 8–9 (Tegner) None 1–2 months
Hallagin C et al. [27] 39 21/18 15.6 ± 1.5 Level 1 or 2 None N
de Jong SN et al. [28] 191 162/29 18–50 Military Meniscus (37) 0.5–15 years
Chondral (4)
McHugh MP et al. [29] 39 25/12 31 ± 9 N Meniscus (23) < 2 months: 15
Grade 2 MCL sprain (2) 2–6 months: 7
Grade 1 MCL sprain (1) > 6 months: 15

N: not reported; No. : number of participants; Tegner: Tegner activity level score; MCL: medial collateral ligament.

strated positive associations between pre-operative and post-op-
erative quadriceps strength, with correlation coefficient ranging
from 0.340 to 0.772 [11, 12, 14, 23, 25, 27–29]. Among the 8 stud-
ies that showed positive association, 2 studies evaluated quadri-
ceps strength by MVIC test [11, 29], while the other 6 studies used
isokinetic test [12, 14, 23, 25, 27, 28]. Lepley LK et al. [11] and Hal-
lagin C et al. [27] reported the positive association between pre-
operative and post-operative normalized quadriceps strength and
the other 5 studies reported positive association between pre-op-
erative and post-operative QSI [12, 23, 25, 28, 29]. In addition, Shi-
bata Y et al. reported that both pre-operative QSI and normalized
quadriceps strength were positively associated with post-operative
QSI [14]. The follow-up duration of the supportive studies ranged
from 3 months to 2 years. On the contrary, Mariani PP et al. [26]
(moderate quality) reported that there was no association between
pre-operative and post-operative QSI. In the study, quadriceps
strength was measured by MVIC test early after injury, and at 2 and
3 months after surgery.
Post-operative quadriceps atrophy
Only 1 study conducted by Zargi TG et al. (moderate quality) inves-
tigated the association between pre-operative quadriceps strength
and post-operative quadriceps atrophy at 4 and 12 weeks after re-
construction [22]. They concluded that pre-operative quadriceps

Qiu J et al. Is Pre-operative Quadriceps Strength … Int J Sports Med

 ▶Table 3 Treatment protocols for participants.

Participant treatment protocols

Study Reconstructed graft Post-operative rehabilitation scheme
Protocol Frequency Duration Compliance
Lepley LK et al. [11] BPTB autograft Started on the 1st week after surgery. The program emphasized full knee 2–3 times/week 7 months N
extension range of motion immediately and knee flexion as tolerated, progres-
sion of functional exercises, quadriceps re-education and muscle strengthening.
Variation between rehabilitation progress was based on concomitant surgery, age
and patient’s response to treatment.
Eitzen I et al. [12] BPTB autograft 2 different protocols, either neuromuscular training program or strength training 2–3 times/week 6 months N
program. The neuromuscular training program consisted of impairment
solutions, balance exercises, dynamic joint stability exercises, plyometric
exercises, agility drills, and sport-specific exercises. The strength training
program emphasized impairment solutions and the strengthening exercises of
quadriceps, hamstring, gluteus medius, and gastrocnemius muscles.

Qiu J et al. Is Pre-operative Quadriceps Strength … Int J Sports Med

Logerstedt D et al. [13] Hamstring autograft or allograft
Shibata Y et al. [14] Hamstring autograft
Zargi TG et al. [22] Hamstring autograft
Ueda Y et al. [23] Hamstring autograft
Heijne A et al. [24] BPTB autograft or Hamstring
autograft
Shelbourne KD et al. [25] BPTB autograft
Mariani PP et al.[26] BPTB autograft
Hallagin C et al. [27] BPTB autograft
de Jong SN et al. [28] BPTB autograft or Hamstring
autograft
McHugh MP et al. [29] BPTB autograft
Started on the 1st week after surgery. The program emphasized impairment < 5 weeks: 2–3 times/ N N
solution, aggressive quadriceps strengthening and neuromuscular training. week; 5–8 weeks: 1–2
Variation between rehabilitation progress was based on patient’s symptoms and times/ week
response to treatment.
Started on the 1st day after surgery. Full weight bearing and full knee extension at N 6 months N
2 weeks post-operation. The program was intended to improve range of motion,
muscle strength, and proprioception. Started jogging at about 3 months after
surgery. The progress of the rehabilitation protocol was based on time.
Full body-bearing on the 1st day + 5-week routine rehabilitation + 2 weeks 3 times/week 7 weeks N
intensified rehabilitation (not report specific rehabilitation protocol.)
Started on the 1st day after surgery. Full weight bearing and full knee extension N 6 months N
at 2 weeks post-operation. The program was intended to improve range of
motion, muscle strength, and proprioception. Started jogging at about 3 months
after surgery. The progress of the rehabilitation protocol was based on time.
Started on the 1st week after surgery. The rehabilitation protocol consisted of N 1 year N
joint and muscle flexibility exercises, strength training mainly focusing on the
thigh muscles, balance and coordination training.
N N N N
N 5 times/week 3 months N
Started on 1st day after surgery. The program compromised impairment 2 times/week 3 months N
solutions, quadriceps, hamstring and hip strengthening exercises, neuromuscular
control training.
Started on 1st week after surgery. The program emphasized impairment N 7 months N
solutions, muscle strengthening exercises, balance training, plyometric training
and sport-specific exercise.
Started on the 1st day after surgery. The program consisted of impairment N 6 months N
solutions, muscle strengthening exercised, proprioception and balance exercise,
plyometric training. Jogging started at about 3 months.

N: not reported; BPTB: bone patellar tendon bone.

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 ▶Table 4 Results of each individual study.

Study Quadriceps strength Pre-operative Post-operative outcomes Follow-up time Results

measurement Parameters points
Review

Associations Predictive value

methods (Mode;
Position)
Lepley LK MVIC; Hip 90 ° flexion, Normalized quadriceps Normalized quadriceps MVIC When patients Normalized MVIC: correlated (R = 0.682,
et al. [11] Knee 90 ° flexion. MVIC return to sports p < 0.001).
Eitzen I Isokinetic concentric QSI; Quadriceps total Cincinnati knee score; QSI. 2 years 1. Cincinnati score: correlated (R = 0.395, QSI: 80 %
et al. [12] contraction at 60 °/s and work. P = 0.005) 2. Pre-operative QSI < 80 %
240 °/s; Hip 90 ° flexion. group had significantly lower QSI than the
group of QSI > 80 % 2 years after the
surgery.
Logerstedt D MVIC; Hip 90 ° flexion, QSI IKDC2000 Scale 6 months IKDC2000 score: correlated (R = 0.33, P =
et al.[13] Knee 90 ° flexion. 0.02).
Shibata Y Isokinetic concentric Normalized quadriceps QSI 6 months 1. Normalized quadriceps strength and (1) Age < 23 years with a preoperative
et al. [14] contraction at 60 °/s; strength (peak torque/ post-operative QSI correlated (R = 0.34, strength index ≥ 7 8.8 %, (2) age ≥ 29
Hip 90 ° flexion. body weight); QSI P < 0.01) 2.Pre-operative QSI and years with a preoperative strength index ≥
post-operative QSI (R = 0.4, P < 0.01) 98.0 %. By contrast, patients ≥ 29 years
with a preoperative strength index < 98.0 %
were likely to achieve a QSI < 70 % at 6
months after surgery. 46.8 % of the patients
were correctly allocated to the groups in
the decision tree analysis.
Zargi TG MVIC; Hip 85 ° flexion; Normalized quadriceps Quadriceps volume loss; 4 weeks; 1. 4 weeks post-operative quadriceps
et al. [22] Knee 60 ° flexion. MVIC (peak torque/ 12 weeks volume loss: no correlation. 2. 12 weeks
body weight) post-operative quadriceps volume loss: no
correlation
Ueda Y Isokinetic concentric QSI QSI 6 months 1. Mean pre-operative QSI was significantly QSI: 70.2 % (AUC = 0.65; sensitivity =
et al. [23] contraction at 60 °/s; higher in the good recovery (GR) (74.1 ± 69.1 %; specificity = 61.5 %).
Hip 90 ° flexion. 22.1) group than in the poor recovery (PR)
(63.1 ± 22.1) group, P < 0.001. 2. QSI:
correlated (OR: 1.02, 95 %CI: 1.01–1.03,
p = 0.015).
Heijne A Isokinetic concentric QSI KOOS- Sport/Rec and 12 months 1. KOOS-QOL scores: correlated with
et al. [24] and eccentric KOOS-QOL scores; Single leg eccentric QSI (R = 0.22, P = 0.08,
contraction at 90 °/s; hop distance symmetry (LIS); significant as P < 0.1) 2. Tegner activity
Hip 90 ° flexion. Tegner activity scale scores: correlated with concentric QSI (R =
0.36, P = 0.004)
Shelbourne Isokinetic concentric QSI Isokinetic quadriceps peak 1 month; 2 Patients who had good preoperative QSI: 90 %
KD et al. [25] contraction at 180 °/s; torque at 180 °/s (involved months; 3 strength had statistically significantly
Hip 90 ° flexion. side post-operatively/ months; 1 year; higher postoperative strength than patients
uninvolved side pre-opera- 2 years who had poor preoperative strength at
tively) each follow- up time.
Mariani PP MVIC; Hip 90 ° flexion, Quadriceps strength QSI 60 days; 90 days Quadriceps strength (QSI): no correlation.
et al. [26] Knee 90 ° flexion. symmetry index (QSI)
Thieme

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 strength was not associated with quadriceps atrophy at 4 weeks
(P = 0.128) or 12 weeks (P = 0.777) after surgery.

Post-operative functional outcomes

Current evidence consistently supports that pre-operative quadri-
ceps strength is positively associated with post-operative function-
al outcomes. Three studies (moderate quality) reported the posi-
tive association between pre-operative quadriceps strength and
post-operative patients reported outcomes [12, 13, 24] and anoth-
QSI: 80 %

er 2 studies (low quality) reported the positive association between

pre-operative quadriceps strength and post-operative single leg
hop distance index (HDI) [28, 29]. For patients reported outcomes,
different studies used different questionnaires including IKDC2000
Normalized quadriceps strength: correlated

symmetry: correlated (R = 0.38, P < 0.05)

1. Quadriceps strength deficits, correlated
postoperatively. At 12 months, there is no
A large preoperative quadriceps strength

[13], Cincinnati Knee Scale [12] and KOOS-QOL [24]. For HDI,
significantly lower LSI at 6 and 9 months

(R = 0.4, P < 0.01). 2. Single leg hop

clear difference between the groups.

McHugh MP et al. [29] concluded that pre-operative quadriceps

deficit (deficit > 20 %) results in a

strength correlated significantly with 6 months post-operative HDI.

de Jong SN et al. [28] reported patients with lower than 80 % QSI
before injury would have practically lower HDI at both 6 and 9
(R = 0.772, p < 0.001).

months after surgery. Only 1 moderate quality study reported the

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significant correlation between pre-operative quadriceps strength
and level of sporting activity at 12 months post-operatively [24].

Predictive values of pre-operative quadriceps

strength
Five studies tried to find a predictive value of pre-operative quadri-
MVIC: maximum voluntary isometric contraction; QSI: quadriceps strength symmetry index; LIS: limb symmetry index.

ceps strength to restore satisfactory quadriceps strength after sur-

6 months; 9
months; 12

gery and all of the 5 studies adopted QSI as the units of the predic-
6 months
12 weeks

months

tive value [12, 14, 23, 25, 28]. However, the value varies from study
to study. The predictive value of pre-operative quadriceps strength
was determined by the stratification of pre-operative QSI of 3 stud-
QSI; Single legged timed hop

Quadriceps strength deficits;

ies [12, 25, 28], and Shibata Y et al. and Ueda Y et al. determined
backward; Crossover hop for
forward; Single-legged hop
(normalized: peak torque/

the predictive value by prediction tree analysis and AUC-ROC anal-

single leg hop distance

ysis respectively [14, 23]. Both of Shibata Y et al. and Ueda Y et al.
Quadriceps strength

regarded 85 % QSI at 6 months after surgery as satisfied quadriceps

symmetry (LSI)

recovery [14, 23]. The predictive value of QSI ranged from 70.4
distance (LSI)
body weight)

–98 % in adult patients.

Discussion
Normalized quadriceps
strength (peak torque/

This is the first systematic review to evaluate the associations be-

Quadriceps strength

tween pre-operative quadriceps strength and post-operative

body weight);

quadriceps strength and functional outcomes in ACLR patients. The

main finding of this systematic review is that pre-operative quadri-
deficits;

ceps strength is positively associated with quadriceps strength and

QSI

functional outcomes after ACLR.

Most evidence supports that pre-operative quadriceps strength
of each individual study.

MVIC; Hip 90 ° flexion,

is positively associated with quadriceps strength following ACLR

contraction at 60 °/s;

contraction at 60 °/s;
Isokinetic concentric

Isokinetic concentric

except for the study of Mariani et al. [26]. The controversial result
Knee 30 ° flexion.
Hip 85 ° flexion.
Hip 90 ° flexion.

from the study of Mariani PP et al. may be due to its small sample
size and shorter follow-up after surgery. Seven out of the 8 studies
[11–14, 23, 25, 28] supporting the positive association between
Continued.

pre-operative and post-operative quadriceps strength followed-up

▶Table 4 Results

the patients to at least 6 months after surgery. Although Hallagin

C et al. found positive association between pre-operative and post-
McHugh MP
de Jong SN
Hallagin C
et al. [27]

et al. [28]

et al. [29]

operative quadriceps strength 3 months after surgery [27], they

used normalized quadriceps strength of the injured leg for pre-post
correlation, whereas Mariani PP et al. used the QSI for correlation

Qiu J et al. Is Pre-operative Quadriceps Strength … Int J Sports Med

 Review
[26]. Previous studies suggested that some of ACL deficient pa-
tients suffered from bilateral quadriceps weakness after injury and
surgery, especially at early stage [30, 31], therefore, QSI may have
the potential to overestimate quadriceps strength at 3 months
post-operatively. To summarize, there is moderate evidence sup-
porting that pre-operative quadriceps strength is positively asso-
ciated with quadriceps strength after ACLR.
Only 1 study investigated the association between pre-operative
quadriceps strength and quadriceps atrophy at the early stage fol-
lowing ACLR and found no association [22]. This finding may be con-
tributed by the complicated alterations in quadriceps morphology
as well as quadriceps inhibition [30, 32, 33]. Muscle size is demon-
strated as a primary determinant of muscle strength in healthy pop-
ulation without joint injury history, but as to ACL deficient patients,
quadriceps atrophy can explain only a limited proportion of its weak-
ness, even at 5 years after the surgery [34, 35]. To summarize, there
is lack of evidence focusing the association between pre-operative
quadriceps strength and post-operative quadriceps atrophy.
Single leg hop symmetry index, patients reported outcomes and ac-
tivity levels are the most commonly used and reliable measurements
for estimating functional outcomes following ACLR [5, 36, 37]. Current
evidence consistently concluded that pre-operative quadriceps strength
is positively correlated with post-operative functional outcomes. Previ-
ous studies reported that patients getting higher pre-operative quadri-
ceps strength have significantly better functional recovery [16, 17]. Two
potential reasons may explain the results. Firstly, patients with stronger
pre-operative quadriceps may have higher post-operative quadriceps
strength, in addition, QSI has been demonstrated to be positively asso-
ciated with HDI, patients reported outcomes and activity level [38–41].
Secondly, patients with stronger quadriceps strength may also have bet-
ter neuromuscular control, because the loss of feedback from mecha-
noreceptors and dysfunction of the gamma loop are contributors to
quadriceps weakness [42]. Therefore, these patients may also achieve
better functional outcomes after surgery. To summarize, weak evidence
supports the positive association of pre-operative quadriceps strength
and functional outcomes following ACLR due to the limited evidence
and low quality of relevant studies.
Although the included studies used different post-operative re-
habilitation protocols, every individual study reported the partici-
pants within each study followed the same post-operative rehabil-
itation protocol. However, none of the included studies reported
the patients’ compliance for the post-operative rehabilitation,
which can be a reason for the relatively low quality of included stud-
ies, leading to a difference in their results. Furthermore, variations
in age, sex, pre-injury activity level, time from injury to surgery, re-
constructed graft and concomitant injuries can also affect quadri-
ceps strength recovery after ACLR [14, 23, 35, 43]. Most of the in-
cluded studies did not control for these confounding factors, which
can lead to the different results and hence the inconclusive finding
for a predictive value of pre-operative quadriceps strength to en-
sure good recovery of quadriceps strength after surgery. Further
studies are needed to investigate the predictive value of pre-oper-
ative quadriceps strength in a homogenous cohort.
The limitations of this systematic review are as follows: Firstly,
there was no high quality study included in this systematic review,
which is mainly due to the heterogeneous cohort with confounding
factors including age, sex, pre-injury activity level, time from injury
Thieme
to surgery, surgical techniques and compliance of post-operative re-
habilitation. Secondly, there is large variation in the measurement
methods of the outcomes. In this systematic review, 5 studies meas-
ured quadriceps strength by MVIC at different knee flexion angles
while 7 studies measured by isokinetic tests at different speeds.
Strength deficits measured by isometric or isokinetic test indicate
deficits in length-force or velocity- force relationship of quadriceps,
which may lead to the difference in the results [44].
Conclusions and Clinical Significance
There is moderate evidence supporting pre-operative quadriceps
strength is positively associated with quadriceps strength after
ACLR; there is weak evidence supporting whether pre-operative
quadriceps strength is positively associated with functional out-
comes after ACLR; and the predictive value of pre-operative quadri-
ceps strength has not been well established.
Pre-operative quadriceps strength should be taken into consid-
eration when predict patient recovery of ACLR. Orthopaedic sur-
Downloaded by: Glasgow University Library. Copyrighted material.
geons and physiotherapists should assess pre-operative quadriceps
strength for patients, and patients with severe quadriceps weak-
ness should be advised to take strengthening exercises to achieve
symmetrical strength prior to surgery.
Conflict of Interest
The authors declare that they have no conflict of interest.
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