Young athletes with quadriceps femoris strength asymmetry at return to sport after anterior cruciate ligament reconstruction demonstrate asymmetric single-leg drop-landing mechanics

Matthew P. Ithurburn, Mark V. Paterno, Kevin R. Ford, Timothy E. Hewett, Laura C. Schmitt

Research output: Contribution to journalArticlepeer-review

94 Scopus citations


Background: Young athletes who have had anterior cruciate ligament (ACL) reconstruction demonstrate suboptimal rates of return to sport, high rates of second ACL injuries, and persistent movement asymmetries. Therefore, the influence of musculoskeletal impairments on movement mechanics in this population needs to be further evaluated. Hypothesis: The primary hypothesis was that among young athletes who have had ACL reconstruction, those with greater quadriceps strength asymmetry would demonstrate altered single-leg drop-landing mechanics at return to sport compared with individuals with more symmetric quadriceps strength and also compared with healthy controls (ie, those with no ACL reconstruction). A second hypothesis was that quadriceps strength symmetry would predict single-leg drop-landing symmetry in individuals who have undergone ACL reconstruction. Study Design: Controlled laboratory study. Methods: The study entailed a total of 103 participants (age, 17.4 years) at the time of return to sport after ACL reconstruction and 47 control participants (age, 17.0 years). The quadriceps index (QI) was calculated for isometric quadriceps strength, which was then used to divide the ACL reconstruction participants into high-quadriceps (QI ≥90%; n = 52) and low-quadriceps (QI <85%; n = 41) subgroups. Biomechanical data were collected by use of 3-dimensional motion analysis during a single-leg drop-landing task. The LSI was calculated for kinematic and kinetic sagittal-plane variables of interest during landing. Group differences were compared by use of 1-way analysis of variance and linear regression analyses (α <.05). Results: Both the low- and high-quadriceps groups demonstrated greater limb asymmetry during landing compared with the control group in knee flexion excursion (mean LSI ± SD: low quadriceps, 85.8% ± 15.5% [P <.001]; high quadriceps, 94.2% ± 15.6% [P =.019]; control, 102.7% ± 14.1%), peak trunk flexion angle (low quadriceps, 129.2% ± 36.6% [P <.001]; high quadriceps, 110.5% ± 22.6% [P =.03]; control, 95.5% ± 26.2%), and peak knee extension moment (low quadriceps, 79.5% ± 25.2% [P <.001]; high quadriceps, 89.9% ± 19.8% [P =.005]; control, 102.2% ± 10.9%). Compared with the high-quadriceps group, the low-quadriceps group also demonstrated greater asymmetry during landing in knee flexion excursion (P =.026), peak trunk flexion angle (P =.006), and peak knee extension moment (P =.034). In the ACL reconstruction group, quadriceps strength symmetry predicted symmetry in knee flexion excursion, peak trunk flexion, and peak knee extension moment (all P <.001) and predicted symmetry in peak trunk flexion angle (P <.001) after controlling for graft type, knee-related pain, function with activities of daily living, and sport function. Conclusion: At the time of return to sport, athletes who had undergone ACL reconstruction, including those in both the high- and low-quadriceps groups, demonstrated asymmetry during a single-leg drop-landing task compared with controls. Compensations included increased trunk flexion, decreased knee flexion excursion, and decreased knee extension moments on the involved limb. In addition, individuals in the low-quadriceps group demonstrated greater movement asymmetry compared with individuals in the high-quadriceps group. Clinical Relevance: Restoration of symmetric quadriceps strength after ACL reconstruction is associated with more symmetric mechanics during a single-leg drop-landing movement. However, this appears to be multifactorial, as the high-quadriceps group also demonstrated landing asymmetries. Restoration of symmetric quadriceps strength may improve postoperative athletic participation; however, future study is warranted.

Original languageEnglish (US)
Pages (from-to)2727-2737
Number of pages11
JournalAmerican Journal of Sports Medicine
Issue number11
StatePublished - Nov 1 2015


  • ACL
  • biomechanics
  • knee
  • motion analysis

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation


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