Knee and ankle biomechanics during recovery from primary, secondary, and bilateral anterior cruciate ligament injuries: a quasi-experimental study
Keywords:
Anterior cruciate ligament reconstruction, Weight-bearing, Rehabilitation, Y-Balance test, Knee movements, Movement system, Ligament diseasesAbstract
BACKGROUND: Anterior cruciate ligament (ACL) tears are common knee injuries with a known but vague association with secondary joint injuries. The extent to which these injuries are preventable remains unclear.
OBJECTIVES: This study aimed to assess the functional differences in knee and ankle dorsiflexion biomechanics with full loading on one leg and to understand whether it could be a key point as a progressive method in ACL reconstruction, considering both legs and three different groups.
DESIGN AND SETTING: A quasi-experimental study of Medical Centers in an outpatient clinic in Portugal
METHODS: The Y balance test (YBT) was used to evaluate and analyze the association between ankle dorsiflexion range of motion (DF-ROM) and knee flexion. DF-ROM and knee flexion were used to compare the deficits between the operated and uninvolved limbs in all three groups (ACL-I, ACL-II, and ACL-III).
RESULTS: Ankle DF-ROM and knee flexion assessed during the YBT were associated with higher knee flexion ROM, identifying individuals who were better prepared for the next phase of the guideline. The study results provide preliminary data for future studies that use prospective longitudinal research and involve large patient populations to establish prognostic biomechanical markers for determining long-term dynamic stability after ACL reconstruction.
CONCLUSIONS: In the three groups with a history of ACL injury, compensations and kinematic asymmetries in dorsal flexion and knee flexion were observed in the operated and control legs both at 6 and 8 weeks of treatment.
Downloads
References
Atik OŞ, Kaya İ. Is it possible to prevent ACL injury? Jt Dis Relat Surg. 2022;33(2):263-4. PMID: 35852183; https://doi.org/10.52312/jdrs.2022.57905.
Jordan MJ, Morris N, Lane M, et al. Monitoring the return to sport transition after acl injury: an alpine ski racing case study. Front Sports Act Living. 2020;2:12. PMID: 33345007; https://doi.org/10.3389/fspor.2020.00012.
Shimizu T, Samaan MA, Tanaka MS, et al. Abnormal biomechanics at 6 months are associated with cartilage degeneration at 3 years after anterior cruciate ligament reconstruction. Arthroscopy. 2019;35(2):511-20. PMID: 30473456; https://doi.org/10.1016/j.arthro.2018.07.033.
Roper JA, Terza MJ, Tillman MD, Hass CJ. Adaptation strategies of individuals with anterior cruciate ligament reconstruction. Orthop J Sports Med. 2016;4(2):2325967115627611. PMID: 26894200; https://doi.org/10.1177/2325967115627611.
Luc-Harkey BA, Harkey MS, Stanley LE, et al. Sagittal plane kinematics predict kinetics during walking gait in individuals with anterior cruciate ligament reconstruction. Clin Biomech. 2016;39:9-13. PMID: 27614716; https://doi.org/10.1016/j.clinbiomech.2016.08.011.
Ogura A, Miyazaki T, Ida H, Shibata S, Takemura M. Postural control during single-leg landing in female athletes after anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2024;19(6):681-91. PMID: 38835982; https://doi.org/10.26603/001c.117400.
Oh J, Ripic Z, Signorile JF, et al. Monitoring joint mechanics in anterior cruciate ligament reconstruction using depth sensor-driven musculoskeletal modeling and statistical parametric mapping. Med Eng Phys. 2022;103:103796. PMID: 35500996; https://doi.org/10.1016/j.medengphy.2022.103796.
Bell DR, Oates DC, Clark MA, Padua DA. Two- and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. J Athl Train. 2013;48(4):442-9. PMID: 23724771; https://doi.org/10.4085/1062-6050-48.3.16.
Sigward SM, Chan MSM, Lin PE, Almansouri SY, Pratt KA. Compensatory strategies that reduce knee extensor demand during a bilateral squat change from 3 to 5 months following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2018;48(9):713-8. PMID: 29895231; https://doi.org/10.2519/jospt.2018.7977.
Di Stasi SL, Logerstedt D, Gardinier ES, Snyder-Mackler L. Gait patterns differ between ACL-reconstructed athletes who pass return-to-sport criteria and those who fail. Am J Sports Med. 2013;41(6):1310-8. PMID: 23562809; https://doi.org/10.1177/0363546513482718.
Korakakis V, Kotsifaki A, Korakaki A, Karanasios S, Whiteley R. Current perspectives and clinical practice of physiotherapists on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists. Phys Ther Sport. 2021;52:103-14. PMID: 34479178; https://doi.org/10.1016/j.ptsp.2021.08.012.
Zhou W, Liu X, Hong Q, Wang J, Luo X. Association between passing return-to-sport testing and re-injury risk in patients after anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis. PeerJ. 2024;12:e17279. https://doi.org/10.7717/peerj.17279.
Yabroudi MA, Bashaireh K, Nawasreh ZH, et al. Rehabilitation duration and time of starting sport-related activities associated with return to the previous level of sports after anterior cruciate ligament reconstruction. Phys Ther Sport. 2021;49:164-70. PMID: 33735637; https://doi.org/10.1016/j.ptsp.2021.02.014.
Greenberg EM, Greenberg ET, Albaugh J, Storey E, Ganley TJ. Rehabilitation practice patterns following anterior cruciate ligament reconstruction: A survey of physical therapists. J Orthop Sports Phys Ther. 2018;48(10):801-11. PMID: 29787697; https://doi.org/10.2519/jospt.2018.8264.
Welling W. Return to sports after an ACL reconstruction in 2024 – A glass half full? A narrative review. Phys Ther Sport. 2024;67:141-8. PMID: 38749349; https://doi.org/10.1016/j.ptsp.2024.05.001.
Law MA, Ko YA, Miller AL, et al. Age, rehabilitation and surgery characteristics are re-injury risk factors for adolescents following anterior cruciate ligament reconstruction. Phys Ther Sport. 2021;49:196-203. PMID: 33765648; https://doi.org/10.1016/j.ptsp.2021.03.003.
Kawashima T, Mutsuzaki H, Watanabe A, et al. Impact of surgical timing on functional outcomes after anterior cruciate ligament reconstruction. J Clin Med. 2024;13(10):2994. PMID: 38792535; https://doi.org/10.3390/jcm13102994.
Sherman D, Birchmeier T, Kuenze CM, et al. Thigh-muscle and patient-reported function early after anterior cruciate ligament reconstruction: Clinical cutoffs unique to graft type and age. J Athl Train. 2020;55(8):826-33. PMID: 32688373; https://doi.org/10.4085/1062-6050-370-19.
Flagg KY, Karavatas SG, Thompson Jr S, Bennett C. Current criteria for return to play after anterior cruciate ligament reconstruction: an evidence-based literature review. Ann Transl Med. 2019;7(Suppl 7):S252. PMID: 31728376; https://doi.org/10.21037/atm.2019.08.23.
Wang LJ, Zeng N, Yan ZP, Li JT, Ni GX. Post-traumatic osteoarthritis following ACL injury. Arthritis Res Ther. 2020;22(1):57. PMID: 32209130; https://doi.org/10.1186/s13075-020-02156-5.
Lai H, Chen X, Huang W, et al. Whether patients with anterior cruciate ligament reconstruction walking at a fast speed show more kinematic asymmetries? Orthop Surg. 2024;16(4):864-72. PMID: 38384169; https://doi.org/10.1111/os.14017.
Criss CR, Lepley AS, Onate JA, et al. Brain activity associated with quadriceps strength deficits after anterior cruciate ligament reconstruction. Sci Rep. 2023;13(1):8043. PMID: 37198275; https://doi.org/10.1038/s41598-023-34260-2.
Van Melick N, Van Cingel REH, Brooijmans F, et al. Evidence-based clinical practice update: Practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016;50(24):1506-15. PMID: 27539507; https://doi.org/10.1136/bjsports-2015-095898.
Nyland J, Pyle B, Richards J, et al. A clinical practice review of therapeutic movement-based anterior cruciate ligament reconstruction return to sports bridge program: the biological, biomechanical and behavioral rationale. Ann Jt. 2023;8:23. PMID: 38529232; https://doi.org/10.21037/aoj-23-3.
Ho KY, Murata A. Asymmetries in dynamic valgus index after anterior cruciate ligament reconstruction: A proof-of-concept study. Int J Environ Res Public Health. 2021;18(13):7047. PMID: 34280984; https://doi.org/10.3390/ijerph18137047.
Sharafoddin-Shirazi F, Letafatkar A, Hogg J, Saatchian V. Biomechanical asymmetries persist after ACL reconstruction: results of a 2-year study. J Exp Orthop. 2020;7(1):86. PMID: 33159260; https://doi.org/10.1186/s40634-020-00301-2. Retraction: J Exp Orthop. 2025;12(2):e70189. PMID: 40226531; https://doi.org/10.1002/jeo2.70189.
Kaiyala M, Hannigan JJ, Traut A, Pollard C. Bilateral movement asymmetries exist in recreational athletes during a 45’ sidestep cut post-anterior cruciate ligament reconstruction. PeerJ. 2024;12:e16948. PMID: 38436020; https://doi.org/10.7717/peerj.16948.
Golberg E, Sommerfeldt M, Pinkoski A, Dennett L, Beaupre L. Anterior cruciate ligament reconstruction return-to-sport decision-making: a scoping review. Sports Health. 2024;16(1):115-23. PMID: 36707977; https://doi.org/10.1177/19417381221147524.
Arhos EK, Capin JJ, Buchanan TS, Snyder-Mackler L. Quadriceps strength symmetry does not modify gait mechanics after anterior cruciate ligament reconstruction, rehabilitation, and return-to-sport training. Am J Sports Med. 2021;49(2):417-25. PMID: 33373534; https://doi.org/10.1177/0363546520980079.
Svantesson E, Piussi R, Beischer S, et al. Only 10% of patients with a concomitant MCL injury return to their preinjury level of sport 1 year after ACL reconstruction: a matched comparison with isolated ACL reconstruction. Sports Health. 2024;16(1):124-35. PMID: 36896698; https://doi.org/10.1177/19417381231157746.
Buller LT, Best MJ, Baraga MG, Kaplan LD. Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med. 2015;3(1):2325967114563664. PMID: 26535368; https://doi.org/10.1177/2325967114563664.
Fan Z, Yan J, Zhou Z, et al. Delayed versus accelerated weight-bearing rehabilitation protocol following anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J Rehabil Med. 2022;54:jrm00260. PMID: 35037693; https://doi.org/10.2340/jrm.v53.1438.
D’Ambrosi R, Meena A, Arora ES, et al. Reconstruction of the anterior cruciate ligament: a historical view. Ann Transl Med. 2023;11(10):364. PMID: 37675316; https://doi.org/10.21037/atm-23-87.
Kochman M, Kasprzak M, Kielar A. ACL Reconstruction: which additional physiotherapy interventions improve early-stage rehabilitation? A systematic review. Int J Environ Res Public Health. 2022;19(23):15893. PMID: 36497965; https://doi.org/10.3390/ijerph192315893.
Butcher NJ, Monsour A, Mew EJ, et al. Guidelines for Reporting Outcomes in Trial Reports: The CONSORT-Outcomes 2022 Extension. JAMA. 2022;328(22):2252-64. PMID: 36511921; https://doi.org/10.1001/jama.2022.21022.
Distefano LJ, Blackburn JT, Marshall SW, et al. Effects of an age-specific anterior cruciate ligament injury prevention program on lower extremity biomechanics in children. Am J Sports Med. 2011;39(5):949-57. PMID: 21285445; https://doi.org/10.1177/0363546510392015.
White K, Di Stasi SL, Smith AH, Snyder-Mackler L. Anterior cruciate ligament-specialized post-operative return-to-sports (ACL-SPORTS) training: A randomized control trial. BMC Musculoskelet Disord. 2013;14:108. PMID: 23522373; https://doi.org/10.1186/1471-2474-14-108.
Ekdahl M, Wang JHC, Ronga M, Fu FH. Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16(10):935-47. PMID: 18633596; https://doi.org/10.1007/s00167-008-0584-0.
Moretti L, Bizzoca D, Cassano GD, et al. Graft intra-articular remodeling and bone incorporation in ACL reconstruction: the state of the art and clinical implications. J Clin Med. 2022;11(22):6704. PMID: 36431181; https://doi.org/10.3390/jcm11226704.
Dewig DR, Mills HR, Evans-Pickett A, Pietrosimone BG, Troy Blackburn J. Aberrant gait biomechanics in individuals with ACL reconstruction are magnified during treadmill walking. J Biomech. 2022;134:110989. PMID: 35152158; https://doi.org/10.1016/j.jbiomech.2022.110989.
Cristiani R, Mikkelsen C, Forssblad M, Engström B, Stålman A. Only one patient out of five achieves symmetrical knee function 6 months after primary anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3461-70. PMID: 30778627; https://doi.org/10.1007/s00167-019-05396-4.
Manske RC, Prohaska D, Lucas B. Recent advances following anterior cruciate ligament reconstruction: Rehabilitation perspectives - Critical reviews in rehabilitation medicine. Curr Rev Musculoskelet Med. 2012;5(1):59-71. PMID: 22249750; https://doi.org/10.1007/s12178-011-9109-4.
Kotsifaki R, Korakakis V, King E, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. Br J Sports Med. 2023;57(9):500-14. PMID: 36731908; https://doi.org/10.1136/bjsports-2022-106158.
Ogrodzka-Ciechanowicz K, Głąb G, Ślusarski J, Gądek A. Quadriceps muscle strength recovery with the use of high tone power therapy after anterior cruciate ligament reconstruction: a randomized controlled trial. BMC Musculoskelet Disord. 2021;22(1):975. PMID: 34814896; https://doi.org/10.1186/s12891-021-04862-w.
Kotsifaki A, Van Rossom S, Whiteley R, et al. Symmetry in triple hop distance hides asymmetries in knee function after ACL reconstruction in athletes at return to sports. Am J Sports Med. 2022;50(2):441-50. PMID: 34889652; https://doi.org/10.1177/03635465211063192.
Manoharan A, Fithian A, Xie V, et al. Return to sports after anterior cruciate ligament reconstruction. Perm J. 2024;28(2):102-8. PMID: 38659351; https://doi.org/10.7812/tpp/23.132.
Adams D, Logerstedt D, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: A criterion-based rehabilitation progression. J Orthop Sports Phys Ther. 2012;42(7):601-14. PMID: 22402434; https://doi.org/10.2519/jospt.2012.3871.
Roos PE, Button K, Van Deursen RWM. Motor control strategies during double leg squat following anterior cruciate ligament rupture and reconstruction: An observational study. J Neuroeng Rehabil. 2014;11:19. PMID: 24581172; https://doi.org/10.1186/1743-0003-11-19.
Ishida T, Samukawa M, Koshino Y, et al. Interlimb asymmetry in knee extension moment during double-leg squatting is associated with persistent quadriceps weakness after ACL reconstruction. Orthop J Sports Med. 2023;11(6):23259671231182105. PMID: 37441507; https://doi.org/10.1177/23259671231182105.
Nagelli C V., Di Stasi S, Wordeman SC, et al. Knee biomechanical deficits during a single-leg landing task are addressed with neuromuscular training in anterior cruciate ligament-reconstructed athletes. Clin J Sport Med. 2021;31(6):E347-53. PMID: 31842056; https://doi.org/10.1097/jsm.0000000000000792.
Donelon TA, Edwards J, Brown M, et al. Differences in biomechanical determinants of ACL injury risk in change of direction tasks between males and females: a systematic review and meta-analysis. Sports Med Open. 2024;10(1):29. PMID: 38561438; https://doi.org/10.1186/s40798-024-00701-z.
Chen P, Wang L, Dong S, et al. Abnormal lower limb biomechanics during a bilateral vertical jump despite the symmetry in single-leg vertical hop height in athletes after ACL reconstruction. Orthop J Sports Med. 2024;12(2):23259671241230989. PMID: 38414664; https://doi.org/10.1177/23259671241230989.
Xu D, Zhou H, Quan W, et al. New insights optimize landing strategies to reduce lower limb injury risk. Cyborg Bionic Syst. 2024;5:0126. PMID: 38778877; https://doi.org/10.34133/cbsystems.0126.
Failla MJ, Arundale AJH, Logerstedt DS, Snyder-Mackler L. Controversies in knee rehabilitation: anterior cruciate ligament injury. Clin Sports Med. 2015;34(2):301-12. PMID: 25818715; https://doi.org/10.1016/j.csm.2014.12.008.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 São Paulo Medical Journal
This work is licensed under a Creative Commons Attribution 4.0 International License.
