Sports Biomechanics

ISSN: 1476-3141 (Print) 1752-6116 (Online) Journal homepage: http://www.tandfonline.com/loi/rspb20

Improvements in landing biomechanics following

anterior cruciate ligament reconstruction in
adolescent athletes

Nicole M. Mueske, Akash R. Patel, J. Lee Pace, Tracy L. Zaslow, Curtis D.

VandenBerg, Mia J. Katzel, Bianca R. Edison & Tishya A. L. Wren

To cite this article: Nicole M. Mueske, Akash R. Patel, J. Lee Pace, Tracy L. Zaslow, Curtis D.
VandenBerg, Mia J. Katzel, Bianca R. Edison & Tishya A. L. Wren (2018): Improvements in landing
biomechanics following anterior cruciate ligament reconstruction in adolescent athletes, Sports
Biomechanics, DOI: 10.1080/14763141.2018.1510539

To link to this article: https://doi.org/10.1080/14763141.2018.1510539

Published online: 02 Oct 2018.

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SPORTS BIOMECHANICS
https://doi.org/10.1080/14763141.2018.1510539

ARTICLE

Improvements in landing biomechanics following anterior

cruciate ligament reconstruction in adolescent athletes
Nicole M. Mueske a, Akash R. Patela, J. Lee Pacea,b, Tracy L. Zaslowa,b,
Curtis D. VandenBerga,b, Mia J. Katzela, Bianca R. Edisona,b and Tishya A. L. Wrena,c,d
a
Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA, USA; bDepartment of
Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA;
c
Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA,
USA; dDepartment of Biomedical Engineering, Viterbi School of Engineering, University of Southern
California, Los Angeles, CA, USA

ABSTRACT ARTICLE HISTORY

Motion analysis offers objective insight into biomechanics, rehabi- Received 22 January 2018
litation progress and return to sport readiness. This study exam- Accepted 3 August 2018
ined changes in three-dimensional movement patterns during KEYWORDS
drop jump landing between early and late stages of rehabilitation Motion analysis; vertical
in adolescent athletes following anterior cruciate ligament recon- drop jump; return to sport;
struction (ACLR). Twenty-four athletes (58% female; mean age ACL injury
15.4 years, SD 1.2) with unilateral ACLR underwent motion analysis
testing 3–6 months and again 6–10 months post-operatively.
Kinematics and kinetics were compared between visits and
between limbs using repeated measures ANOVA. The operative
side exhibited lower vertical ground reaction force, less energy
absorption and lower sagittal external moments at the knee and
ankle, and lower peak dorsiflexion angles compared with the non-
operative side regardless of visit. Between visits, hip and knee
flexion increased bilaterally, as well as hip flexion moments and
energy absorption. During early rehabilitation following ACLR,
adolescent athletes reduced flexion and loading of the knee and
ankle on their operative limb. Motion and loading increased over
time, particularly at the hip, but remained reduced at the knee and
ankle 6–10 months post-operatively.

Introduction
Anterior cruciate ligament (ACL) injuries are among the most common in sports,
particularly in adolescents (Dai, Herman, Liu, Garrett, & Yu, 2012; LaBella,
Hennrikus, & Hewett, 2014; Moses, Orchard, & Orchard, 2012). Epidemiologic data
suggest that the overall incidence of ACL injury gradually increases from 0.11 per
10,000 at 8 years of age to 2.42 per 10,000 by 14 years of age (Anderson & Anderson,
2017; Gornitzky et al., 2015). Though ACL reconstruction (ACLR) is the preferred
treatment for young athletes returning to cutting and pivoting activity, those athletes
under 25 years of age who return to sport have a subsequent ACL injury rate of 23%
(Wiggins et al., 2016). A reported 81% of athletes 6–19 years old returning to

CONTACT Nicole M. Mueske nmueske@chla.usc.edu

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 N. M. MUESKE ET AL.

competition coupled with this high rate of additional injury necessitate a better
understanding of the deficits present during the rehabilitation process following
ACLR (Kay et al., 2018).
Common clinical criteria for return to sport after ACLR include time since surgery,
having a stable knee joint, symmetry of thigh girth, strength, hop test performance and
qualitative movement assessment; however, consensus is lacking regarding the optimal
combination of requirements for safe return to sport (Petersen, Taheri, Forkel, &
Zantop, 2014; Petersen & Zantop, 2013). Due to the high rate of additional injury
following return to sport from ACLR, additional objective measures are necessary to
ensure safe return and decrease the likelihood of subsequent injury. While primary and
repeat noncontact ACL injuries have a variety of etiological contributors, including
hormonal, anatomical and neuromuscular influences, neuromuscular factors are of
particular interest because they may be improved through training during rehabilitation
(Boden, Dean, Feagin, & Garrett, 2000; Hewett et al., 2005).
It has been posited that the ACL may experience hazardous three-dimensional (3D)
forces during landing or twisting movements if the knee joint is not stabilised and the
surrounding musculature fails to sufficiently dissipate the associated torques and forces
(Hewett et al., 2005). Specifically, Hewett et al. (2005) found higher knee abduction
moments and posturing during a drop jump landing to be predictive of ACL injury,
Krosshaug et al. (2016) determined the primary factor to be medial knee displacement,
while Leppanen et al. (2016) observed that stiff landings, characterised by low knee flexion
and high vertical ground reaction force (GRF), were associated with increased risk of ACL
injury. Additionally, Paterno et al. (2010) reported higher hip internal rotation moments,
side-to-side asymmetry in knee flexion moments, 2D frontal plane knee range of motion
and single leg postural stability deficits to be significant predictors of subsequent injury
following return to sport after ACLR. These risky biomechanical patterns can be identified
using 3D motion analysis (Hewett et al., 2005; Krosshaug et al., 2016; Leppanen et al., 2016)
and should be corrected during rehabilitation prior to returning to sport.
Preparing an athlete to return to sport after ACLR and determining when they are
ready to safely return are challenging. Understanding changes in landing biomechanics
during rehabilitation may help guide physicians and therapists in evaluating athletes,
defining rehabilitation goals and making return to sport decisions. This study examined
longitudinal changes in 3D movement patterns during vertical drop jump (VDJ) land-
ing between early and late stages of rehabilitation in adolescent athletes who had
undergone unilateral ACLR. It was hypothesised that decreased dynamic limb valgus
and improved sagittal plane shock absorption strategies would be observed as athletes
progressed through rehabilitation, indicating greater readiness to return to sport.

Methods
This retrospective study examined data from all unilateral ACLR patients who were
referred to our motion and sports analysis laboratory for biomechanical assessments
3–6 months (visit 1) and again 6–10 months (visit 2) post-operatively between
December 2013 and April 2017. Our surgeons attempt to refer all post-ACLR patients
for sports biomechanical testing during these ‘early’ and ‘late’ rehabilitation periods;
however, many are not willing or able to attend one or both sessions for logistical
 SPORTS BIOMECHANICS 3

reasons such as travel/time constraints or lack of insurance authorisation. Initially, 115

patients were identified who had undergone at least one sports biomechanical assess-
ment during the designated time period. Patients were then excluded if they had a
history of additional lower extremity injury/surgery (n = 2), the ACL injury involved
contact (n = 12), only one biomechanical assessment was completed (n = 66), one of the
assessments occurred outside of the target time frame (n = 9) or drop jump data were
not complete (n = 2). The final sample included 24 patients (14 female, mean age
14.7 years, range 10.7–17.2; 10 male, mean age 16.3 years, range 13.0–17.7; Table 1).
Nineteen patients had a concomitant meniscus repair and 1 a medial collateral ligament
repair. Patients were not yet cleared to return to sport at the time of either motion
analysis assessment. Informed consent and assent were obtained from parents and
participants in accordance with protocols approved by the Children’s Hospital Los
Angeles Institutional Review Board. A waiver of consent approved by the IRB was
used to access some patient data retrospectively.
All patients were referred for physical therapy and expected to follow a similar
stepwise rehabilitation protocol, though physical therapy programmes were individua-
lised for each patient. Rehabilitation initially focused on range of motion, gait restora-
tion and isometric strengthening with continued strengthening and neuromuscular re-
education in the first 3 months. Rehabilitation then progressed to impact activities and
higher level neuromuscular re-education with emphasis on enhanced control of the
gluteal, core and hamstring muscles at 3–6 months, followed by plyometrics and sports-
specific training at 6–12 months.
For the VDJ, participants were instructed to drop off a 41-cm box, land with both
feet and then immediately jump straight up as high as possible; for the initial landing to
be considered successful, both feet had to land cleanly on separate force plates. Prior to
data collection, each participant was asked to warm up as s/he typically would during a
physical therapy session, including functional warm ups, followed by about 60 s of
walking and a minimum of 90 s of jogging on a treadmill. Prior to data collection, each
participant completed two to three practice trials. Three data collection trials were then
performed and a minimum of two were averaged for analysis.
3D lower extremity kinematic data were recorded during the VDJ using an 8–10
camera motion capture system at 120 Hz (Vicon 612 or Nexus 2, Vicon Motion
Systems Ltd., Oxford, UK); marker trajectories were filtered with a Woltring filter

Table 1. Demographics and clinical characteristics (n = 24).

Visit 1 Visit 2
Age (years) 15.4 ± 1.2 15.7 ± 1.8
Female (%) 14 (58%)
Height (m) 1.67 ± 0.13 1.68 ± 0.13
Weight (kg) 62.5 ± 12.7 63.3 ± 12.6
BMI (kg/m2) 22.1 ± 2.8 22.3 ± 3.1
Time since surgery (months) 4.5 ± 0.7 7.7 ± 1.3
Time between visits (months) 3.3 ± 1.1
Autograft type 12 Hamstring tendon
6 Patellar tendon
3 Iliotibial band
3 Quadriceps tendon
Meniscal involvement (%) 19 (79%)
Single sport athletes (%) 13 (54%)
Continuous variables are presented as mean ± SD. Categorical variables are presented as n (%).
4 N. M. MUESKE ET AL.

with a mean squared error of 10 mm2. GRFs were recorded with analogue force
plates (AMTI OR6-5, Advanced Medical Terminology, Inc., Watertown, MA,
USA) at 2,400 Hz then downsampled to 120 Hz to match the frequency of the
marker trajectories prior to analysis of forces. A modified Plug-in-Gait (PiG)
(Davis, Ounpuu, Tyburski, & Gage, 1991) marker set was used with a patella
marker in place of the thigh wand (Wren, Do, Hara, & Rethlefsen, 2008) and a
marker placed directly over the proximal tibial crest in place of the tibia wand
(Nazareth, Mueske, & Wren, 2016; Peters, Sangeux, Morris, & Baker, 2009). All
markers were placed directly on the skin, with the exception of the foot markers
which were placed on the shoes. The knee axis was defined using knee alignment
devices, which create virtual markers to define the knee flexion axis based on
visual alignment of physical axes by the assessor (Kadaba, Ramakrishnan, &
Wootten, 1990), and the ankle axis was defined using markers on the medial
and lateral malleoli. Kinetics were calculated through inverse dynamics using
standard commercial software (Vicon Workstation or Nexus 2). All data were
collected in the same laboratory (with an equipment upgrade from Vicon 612/
Workstation to Nexus in 2015), and marker placement was performed by one of
two experienced motion laboratory physiotherapists who have specialised training
in sports biomechanics assessment and are tested for reliability of marker place-
ment annually. Accuracy and consistency of data collection were ensured through-
out the study period and through the equipment upgrade by daily calibration and
monthly checks of the motion capture system using the Standard Assessment of
Motion System Accuracy (Piazza et al., 2007). Intra- and inter-assessor reliability
(SD) for our physiotherapists for kinematics are <2.8° and 3.5°, respectively
(Schwartz, Trost, & Wervey, 2004).
Kinematic and kinetic measures were evaluated between initial foot contact and
maximum knee flexion of the first landing; initial contact was defined as the first frame
in which the force plate registered a force greater than 10 N. This deceleration phase of
landing was studied because it is the period in which the majority of non-contact ACL
injuries occur (Boden et al., 2000); furthermore, it encompasses the phases where
abnormal biomechanics have been associated with increased risk of ACL injury
(Hewett et al., 2005; Krosshaug et al., 2007). The outcome measures examined were
those associated with sagittal plane shock absorption (peak vertical GRF, hip and knee
flexion, ankle dorsiflexion, average flexion moments and energy absorption at the hip,
knee and ankle) and dynamic limb valgus (average hip adduction and internal rotation
angles and moments, average knee adduction angle and moment). Positive values
indicate flexion, adduction and internal rotation. External moments are reported with
positive values indicating hip and knee flexion moments, ankle dorsiflexion moments
and knee adduction moments. Energy absorption was calculated as sagittal plane net
joint power integrated over time from initial contact to maximum knee flexion in
regions with negative internal power.
For the primary analysis, two-way repeated measures ANOVA was used to assess
differences between limbs (operative vs. non-operative) and visits (1 vs. 2), including a
limb × visit interaction. Based on the results, post-hoc tests were not needed. All
statistical analyses were performed using STATA (version 14.0, StataCorp LP, College
Station, TX, USA) with a significance level of 0.05.
 SPORTS BIOMECHANICS 5

Results
The operative limb had significantly lower vertical GRF compared to the non-operative
limb regardless of visit, along with lower knee and ankle sagittal plane moments and
energy absorption (Table 2, Figure 1). Additionally, the operative limb had lower peak
dorsiflexion angles compared to the non-operative limb. Energy absorption, flexion
moments and peak flexion angles at the hip increased significantly from visit 1 to visit 2
regardless of side but did not differ between sides irrespective of visit. A significant
increase in peak knee flexion angle was observed between visits regardless of side, but
there was no significant difference in peak knee flexion between sides. No changes
between visits were observed at the ankle.
In the frontal plane, operative limbs exhibited higher hip and knee abduction
moments than contralateral limbs regardless of visit (Table 2); hip abduction moments
increased between visits regardless of side (Tables 2 and 3). The hips became slightly
more abducted and internally rotated at visit 2 compared to visit 1, while the knees
became more adducted (Table 3). No significant asymmetries were observed in hip or
knee frontal or transverse plane angles regardless of visit (Table 2).

Discussion and implications

Multiple studies have concluded that there is an increased risk for second ACL injury
even after the preferred treatment of ACLR (Paterno, Rauh, Schmitt, Ford, & Hewett,
2014; Paterno et al., 2010; Waldén, Hägglund, Ekstrand, Walden, & Hagglund, 2006).

Table 2. Two-way ANOVA results: Initial contact to peak knee flexion kinematics and kinetics
during the vertical drop jump at visits 1 and 2.
Visit 1 (3–6 months Visit 2 (6–10 months
post-op) post-op) ANOVA p-values
Main Main
Non- Non- effect effect Interaction
Operative operative Operative operative limb visit limb × visit
Peak GRF (multiples of body 1.6 ± 0.4 2.2 ± 0.5 1.7 ± 0.4 2.1 ± 0.4 <0.001 0.985 0.111
weight)
Peak hip flexion (°) 97 ± 13 97 ± 13 103 ± 13 104 ± 13 0.815 0.027 0.902
Avg hip flexion moment 1.0 ± 0.3 1.0 ± 0.4 1.2 ± 0.4 1.2 ± 0.3 0.784 0.004 0.884
(Nm/kg)
Hip energy absorption (J/kg) 0.9 ± 0.3 0.9 ± 0.4 1.1 ± 0.3 1.2 ± 0.3 0.465 <0.001 0.967
Peak knee flexion (°) 96 ± 12 100 ± 12 103 ± 15 107 ± 13 0.159 0.017 0.885
Peak knee flexion moment 1.5 ± 0.5 2.0 ± 0.5 1.6 ± 0.5 1.9 ± 0.5 <0.001 0.644 0.337
(Nm/kg)
Knee energy absorption (J/kg) 0.9 ± 0.3 1.5 ± 0.5 1.0 ± 0.5 1.4 ± 0.5 <0.001 0.636 0.167
Peak ankle dorsiflexion (°) 26 ± 7 30 ±8 27 ± 5 29 ± 5 0.030 0.999 0.721
Avg ankle dorsiflexion moment 1.1 ± 0.3 1.4 ± 0.3 1.0 ± 0.3 1.3 ± 0.3 <0.001 0.079 0.689
(Nm/kg)
Ankle energy absorption (J/kg) 0.5 ± 0.2 0.8 ± 0.3 0.5 ± 0.2 0.7 ± 0.2 <0.001 0.139 0.553
Avg hip internal rotation (°) 2±8 2 ±8 5±6 5±6 0.785 0.032 0.906
Avg hip rotation moment 0.1 ± 0.1 0.1 ± 0.1 0.2 ± 0.1 0.1 ± 0.2 0.409 0.208 0.844
(Nm/kg)
Avg hip adduction (°) −10 ± 7 −13 ±6 −14 ± 6 −16 ± 7 0.175 0.024 0.914
Avg hip adduction moment −0.1 ± 0.3 0.04 ± 0.2 −0.2 ± 0.2 −0.1 ± 0.3 0.047 0.006 0.513
(Nm/kg)
Avg knee adduction (°) 1±7 1 ±6 4±4 4±4 0.739 0.026 0.854
Avg knee adduction moment −0.1 ± 0.2 −0.01 ± 0.2 −0.1 ± 0.1 −0.01 ± 0.2 0.005 0.753 0.726
(Nm/kg)
Descriptive data are presented as mean ± standard deviation.
p-values from two-way repeated measures ANOVA.
 6
N. M. MUESKE ET AL.

Figure 1. Average trace plots for sagittal plane joint angles, moments and power during the initial landing (initial foot contact to peak knee flexion) of a vertical
drop jump.
 SPORTS BIOMECHANICS 7

Table 3. Initial contact to peak knee flexion kinematic and kinetic changes between
visits during the vertical drop jump.
Operative Non-operative
Change Change
Mean ± SD Mean ± SD
Peak vertical GRF (multiples of body weight) 0.14 ± 0.35 −0.14 ± 0.49
Peak hip flexion (°) 6 ± 13 6 ± 14
Avg hip flexion moment (Nm/kg) 0.2 ± 0.3 0.2 ± 0.3
Hip energy absorption (J/kg) 0.2 ± 0.4 0.2 ± 0.4
Peak knee flexion (°) 7 ± 12 6 ± 11
Avg knee flexion moment (Nm/kg) 0.03 ± 0.2 −0.08 ± 0.2
Knee energy absorption (J/kg) 0.2 ± 0.3 0.09 ± 0.3
Peak ankle plantarflexion (°) 1±7 −1 ± 5
Avg ankle dorsiflexion moment (Nm/kg) −0.06 ± 0.2 −0.09 ± 0.3
Ankle energy absorption (J/kg) −0.04 ± 0.2 −0.09 ± 0.2
Avg hip internal rotation (°) 3 ± 10 3±7
Avg hip rotation moment (Nm/kg) 0.04 ± 0.1 0.03 ± 0.2
Avg hip adduction (°) −3 ± 6 −3 ± 6
Avg hip adduction moment (Nm/kg) −0.1 ± 0.3 −0.2 ± 0.3
Avg knee adduction (°) 3±7 3±6
Avg knee adduction moment (Nm/kg) 0.02 ± 0.2 −0.001 ± 0.2
Descriptive data are presented as mean ± standard deviation.
Change is the difference from visit 1 to visit 2. Positive values indicate an increase from visit 1 to
visit 2; negative values indicate a decrease from visit 1 to visit 2.
Bold indicates significant main effect for visit based on 2-way ANOVA (see Table 2).

Most notably, Paterno et al. (2014) found that paediatric athletes were 6 times more
likely to experience a second ACL injury within 24 months of ACLR and return to sport
compared to healthy controls with no history of ACL injury. Consequently, controversy
exists as to when and whether return to full sports participation is the correct option for
every athlete (Delahunt et al., 2012). A 2010 study found altered neuromuscular control
of the hip and knee during landing and postural stability deficits after initial ACLR to
be significant predictors of second ACL injury after return to sport (Paterno et al.,
2010). As these potential risk factors for re-injury have also been observed in athletes
more than 2 years after ACLR (Paterno, Ford, Myer, Heyl, & Hewett, 2007), ensuring
appropriate motion and resolution of biomechanical deficits prior to return to sport
may help ensure a safer return. Physicians and athletes both may benefit from the use of
objective measures of functional changes throughout rehabilitation to guide rehabilita-
tion and help determine appropriate return to sport timing.
Subtle pathologic movement patterns are difficult to discern in real time with simple
observation, and additional objective criteria for rehabilitation progress and return to sport
readiness can aid physicians and therapists when evaluating athletes after ACLR. This study
investigated the changes in 3D movement patterns during VDJ landing between early (3–
6 months post-ACLR) and late (6–10 months post-ACLR) stages of rehabilitation in paedia-
tric and adolescent athletes who underwent ACLR. The results show that during early
rehabilitation, the athletes significantly reduced loading of the knee and ankle on their
operative limb compared to the contralateral side during VDJ landing. Loading on the
operative limb remained reduced relative to the contralateral side 6–10 months post-opera-
tively suggesting a persistent avoidance strategy. Current ACLR post-surgical protocols
anticipate reduced knee flexion and range of motion during the intermediate and late post-
operative periods (Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder-Mackler, 2012), and
the current study’s results suggest a strategy indicative of a persistent avoidance mechanism
8 N. M. MUESKE ET AL.

throughout rehabilitation. Ford, Schmitt, Hewett and Paterno (2016) observed that 71% of
participants who previously underwent ACLR preferred to contact the ground first with their
uninvolved limb during VDJ landing. This study’s results suggest a similar landing strategy
characterised by reduced vertical GRF and loading at the knee and ankle in the operative limb.
To successfully return to sports activity, athletes must be able to perform agility and sport-
specific movements without apprehension (Adams et al., 2012) and must be able to land with
either limb contacting the ground first. During rehabilitation, awareness of body positioning
and cuing may be helpful in alleviating apprehension and resolving loading asymmetries.
No sagittal plane hip asymmetries were observed at either visit, though hip flexion
angles, moments and energy absorption increased bilaterally from the first to second
visit. These changes observed at the hip may indicate better proximal control and ability
to translate and distribute force up the chain from the ankle to knee to hip. Since the
hip plays a crucial role in maintaining stability between the trunk and the knee and
dysfunction at the hip may result in altered knee loading and increased ACL injury risk
(Noehren, Abraham, Curry, Johnson, & Ireland, 2014), improvement in overall hip
function is important in return to sport progression. Moreover, past work has found
that baseline hip external rotation strength and abduction independently predict future
noncontact ACL injuries in competitive athletes (Khayambashi, Ghoddosi, Straub, &
Powers, 2016). Previous researchers have suggested that training musculature that
stabilises the knee may help improve proximal control and found that athletes who
engaged in a jump training programme decreased the overall incidence of initial ACL
injury (Hewett, Lindenfeld, Riccobene, & Noyes, 1999). The current study’s findings
support that post-surgical rehabilitation improves athletes’ overall hip function, which
can be detected by a VDJ task.
In contrast to the sagittal plane changes, only slight asymmetries were noted in the
frontal and transverse planes. There were several small, though statistically significant,
changes in frontal and transverse plane kinematic and kinetic variables. These changes
were close in magnitude to the variability of the measurement technique and may not
be clinically significant. Previous work has identified components of dynamic limb
valgus, including knee abduction angle and moments along with hip adduction and
internal rotation, to be risk factors for ACL injury (Hewett et al., 2005; Krosshaug et al.,
2016); however, neither limb demonstrated these patterns, with the exception of a small
knee abduction moment bilaterally at both visits. Perhaps the lack of dynamic limb
valgus is due to rehabilitation that specifically addressed correction of this pattern,
particularly in the operative limb. Alternatively, it is possible differences in the frontal
and transverse planes were masked due to limitations of motion capture technology.
The limitations of this study include its retrospective design, which precluded the
collection of other outcomes data, such as Pediatric International Knee Documentation
Committee (Pedi-IKDC) scores. Also, because this study included only clinical patients,
individual rehabilitation programmes were not controlled and rehabilitation specific data
were not available. Therefore, we cannot evaluate how physiotherapy affected the observed
changes rather than simply recovery over time. Due to small sample size, we were unable to
stratify analyses by sex, age or graft type. There may be advantages and disadvantages
specific to different graft types, and it is possible that the heterogeneity of the graft types
included in this study masked additional effects of the rehabilitation (Cavaignac et al., 2017;
Spragg, Chen, Mirzayan, Love, & Maletis, 2016). Additionally, the PiG model constrains the
 SPORTS BIOMECHANICS 9

knee joint and has been previously found to have higher variability for frontal and
transverse plane variables than for sagittal plane variables, potentially contributing to the
lack of consistent and significant changes in frontal and transverse plane variables.
Moreover, variability of marker placement between visits and between physiotherapists
may have limited the ability to detect possible frontal and transverse plane effects. Finally,
currently, it is unclear if full kinematic and kinetic symmetry should be the goal following
ACLR as, to our knowledge, there are no systematic prospective studies evaluating biome-
chanical asymmetries and injury risk although a double-leg task such as VDJ tends to
produce symmetric landing forces in uninjured adult athletes (Paterno et al., 2007).
This study shows that there are quantifiable changes in landing biomechanics during
the course of rehabilitation following ACLR, particularly at the hip. These changes as
well as lingering deficits and asymmetries can be detected using 3D motion analysis
during a VDJ task highlighting the clinical usefulness of this tool. Improvements in
biomechanics detected by 3D motion analysis may provide insight into the resolution of
an initial avoidance mechanism and the development of increased proximal control
throughout rehabilitation after ACLR and help determine readiness for return to sports.

Conclusion
During early rehabilitation, paediatric and adolescent athletes with ACLR reduce
flexion and loading of the knee and ankle on their operative limb, possibly representing
an avoidance mechanism. These deficits are still present 6–10 months post-operatively.
Increased hip flexion motion, moments and energy absorption may indicate improve-
ments in proximal control as rehabilitation progresses, which may aide in compensa-
tion for persistent deficiencies at the knee. Motion analysis can quantify resolution of
this avoidance mechanism and improvements in proximal control over time, which
may be used to track rehabilitation progress and evaluate return to sport readiness after
ACLR. Resolution of asymmetric loading and motion during dynamic tasks should be
considered in return to sport protocols in addition to currently used measures such as
range of motion, strength and performance on simple functional tests such as the single
leg hop for distance. Given the persistence of knee offloading after ACLR, attention
should also be paid to improving proximal control as a compensatory movement
strategy.

Acknowledgements
The authors would like to thank our Sports Motion Lab team—Bitte Healy, Henry Lopez and
Kyle Chadwick for their help with data collection and data processing.

Disclosure statement
One author is a consultant for Arthex and Ceterix, and another receives general research support
from Neural Analytics; no company was involved in any aspect of this study. The remaining
authors have no conflicts of interest to declare.
10 N. M. MUESKE ET AL.

ORCID
Nicole M. Mueske http://orcid.org/0000-0003-4459-8289

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