Orthopaedics & Traumatology: Surgery & Research (2010) 96S, S119—S128

REVIEW ARTICLE

ACL injury and reconstruction: Clinical related in

vivo biomechanics
A.D. Georgoulis ∗, S. Ristanis , C.O. Moraiti , N. Paschos , F. Zampeli ,
S. Xergia , S. Georgiou , K. Patras , H.S. Vasiliadis , G. Mitsionis

Orthopaedic Sports Medicine Center of Ioannina, Department of Orthopaedic Surgery, University of Ioannina,
Georgiou Papandreou 2, PO Box 1042, Ioannina 45110, Greece

KEYWORDS Summary Several researchers including our group have shown that knee joint biomechanics
ACL reconstruction; are impaired after anterior cruciate ligament (ACL) injury, in terms of kinematics and neuro-
Tibial rotation; muscular control. Current ACL reconstruction techniques do not seem to fully restore these
Electromechanical adaptations. Our research has demonstrated that after ACL reconstruction, excessive tibial
delay; rotation is still present in high-demanding activities that involve both anterior and rotational
Gait variability; loading of the knee. These findings seem to persist regardless of the autograft selection for the
Muscle strength; ACL reconstruction. Our results also suggest an impairment of neuromuscular control after ACL
Knee biomechanics; reconstruction, although muscle strength may have been reinstated. These abnormal biome-
Sports performance chanical patterns may lead to loading of cartilage areas, which are not commonly loaded in the
healthy knee and longitudinally can lead to osteoarthritis. Muscle imbalance can also influence
patients’ optimal sports performance exposing them to increased possibility of knee re-injury.
In this review, our recommendations point towards further experimental work with in vivo and
in vitro studies, in order to assist in the development of new surgical procedures that could
possibly replicate more closely the natural ACL anatomy and prevent future knee pathology.
© 2010 Elsevier Masson SAS. All rights reserved.

Introduction to coupled internal rotation [5,6]. The ACL is the guide of

the screw-home mechanism. This refers to an ‘‘automatic’’
The anterior cruciate ligament (ACL) is composed of two type of axial rotation that is inevitably and involuntarily
functional bundles, the anteromedial (AM) and the postero- linked to movements of flexion and extension. When the
lateral (PL) named by their tibial attachment [1—4]. Tension knee is flexed, the tibia is internally rotated. As the knee
in the AM bundle increases with knee flexion, whereas the PL is extended, the femoral condyles roll and glide on the
bundle takes up greater tension in extension and in response tibial condyles, the tibia is gradually externally rotated
and at full extension the knee joint ‘‘locks’’ presenting
the maximal stability at the upright standing position. This
screw-home mechanism is very important for the synchro-
∗ Corresponding author. Tel.:/fax: +30 26510 64980. nization of the knee joint to the adjacent joints of the hip
E-mail address: [email protected] (A.D. Georgoulis). and the ankle. Although the principal movement of the knee

1877-0568/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2010.09.004
S120 A.D. Georgoulis et al.

is flexion-extension, the internal-external rotation plays a [19]. ‘Leg dominance’ is the side-to-side imbalance on
very significant role especially in all these activities that strength and coordination between the dominant and the
include pivoting. other leg, which may increase the risk for both limbs
In the clinical setting, the anterior tibial translation is [19—21].
estimated with the Lachman-Noulis test, a reliable noninva- The prevention programs have focused on neuromus-
sive diagnostic test for the ACL rupture. As Paessler H. and cular training methods to change the above-described
Michel D. reported [7], this test was originally described by modifiable biomechanical and neuromuscular risk factors
George K. Noulis (1849—1919) in his doctoral thesis ‘‘Entorse and to reduce the non-contact ACL injury rates [22].
du genou’’ which was defended at the University of Paris in Most of these effective prevention studies included a
1875 [8]. This was perhaps the first biomechanical study on combination of proprioceptive, neuromuscular and core bal-
knee ligaments in cadavers. ance training, plyometric, closed kinetic chain and other
Aristotle (384—322 BC) stated the principal idea that strengthening exercises, in order to modify the sport-
‘‘every movement requires a cause’’. This is the main core specific movement patterns that lead to increased ACL
of interest of the in vivo biomechanics. The movement is injury risk.
studied with the kinematics and the cause is studied with More specific, the intervention programs focus on nor-
the kinetics. Through its long history, in vivo biomechanics malizing the landing technique [23], decreasing the valgus
can nowadays be a valuable tool also for the arthroscopic and internal/external rotation moments on cutting maneu-
surgeon. In recent years, important findings with clinical vers [23] and increasing the hamstrings [19,24] and gluteal
relevance have arisen from in vivo biomechanical studies [25] muscles recruitment and strength.
and have improved our understanding for the ACL deficient
and the ACL reconstructed knee and more interestingly has
influenced even the way that we operate these patients.
The current review article presents significant amount of Rupture pattern and injury mechanism of the
knowledge regarding the in vivo biomechanics of an ACL- ACL
deficient patient, starting from the ACL rupture, including
the ACL reconstruction and being completed with the return ACL injury is very common during athletic performance
to sports and previous activity level. compared to the incidence in the general population [26].
Recently, the interest on ACL failure has been increased
since several studies highlight ACL injury as a risk fac-
ACL injury risk factors and prevention tor for knee osteoarthritis regardless of ACL reconstruction
[27,28]. During ACL injury, the most common symptoms
In team sport settings, 50 to 80% of ACL injuries include pain, audible pop, and oedema. The presence and
occur in non-contact situations [9—11]. The risk fac- importance of these signs in relation to isolated ACL injury
tors for a non-contact ACL injury can be divided into have been evaluated in the past [29]. Several studies have
four categories: environmental, anatomical, hormonal and contributed in better understanding of the biomechani-
biomechanical—neuromuscular [12]. From a biomechanical cal properties of the ACL like strength [30], stiffness [31]
perspective, ACL is loaded not only by extreme anterior and tension patterns in relation to its failure properties
translation, but also by both valgus and internal rotation [32].
moments. In fact, during landing and sidestep cutting tasks, A very interesting point is that a part of ACL fibers fail
anterior drawer load in isolation is probably not sufficient initially while the rest remain intact and have the ability
to injure the ACL and rather a loading combination on the to withstand load [32]. This condition could represent the
three movement planes is needed to increase the likeli- partial ACL tear or the tear of only the AM or the PL bundle
hood of rupture. Besides that, when the knee flexion angle of the ACL. Three different patterns have been described in
increases, there is a reduction in the resultant strain on the both in vitro and in vivo studies. All of these agree that the
ACL [13—17]. final pattern is related to the biomechanical features of the
The following biomechanical factors are not directly con- ACL and the mechanism of the injury [33,34].
nected with the actual knee movement patterns, but also Acute ACL rupture is accompanied in more than 80%
seem to play an important role on increasing the injury risk: by bone bruises, shown in MRI scanning. Spindler et al.
decreased core stabilization and balance, low trunk and hip [35] showed that 86% and 67% of the contusions involved
flexion angles and high ankle dorsiflexion when performing the lateral femoral condyle (LFC) and lateral tibial plateau
sport tasks. Furthermore, the combination of lateral trunk (LTP) respectively; in 56% of the cases, bruises at both
displacement with increased knee abduction moments and sides occurred. Lesions in the medial femoral condyle (MFC)
increased hip internal rotation with tibial external rotation and medial tibia plateau (MTP) were less common (7%
exposes the ACL in high risk [13]. and 21% respectively). During the ACL injury, the tibia
Neuromuscular deficiencies are also commonly observed subluxes anteriorly and rotates internally subjecting the
in female athletes and have been classified in three cate- anterior parts of femoral condyles and posterior parts of
gories: The ‘ligament dominance’ appears when an athlete tibial plateaus to direct contact. The excessive internal
absorb a significant portion of the ground reaction force dur- rotation of the tibia explains why the contusions of the
ing sports maneuvers with the knee ligaments, rather than LFC are usually more anterior than those seen on the
the lower extremity musculature [18]. ‘Quadriceps domi- MFC [36]. The axial and valgus force applied on the knee
nance’ is the preferential activation of the knee extensors especially during contact injuries also plays an important
over the knee flexors during high-torque force movements role.
Biomechanics in ACL injury and reconstruction S121

Clinical related in vivo biomechanics controls during an even higher demanding activity, like land-
ing from a platform and subsequent pivoting (Fig. 2), which
Pathological internal-external rotation after ACL could apply increased rotational loading at the knee. We
found no significant differences between the deficient leg
injury and reconstruction
of the ACL-deficient group and the reconstructed leg of
the ACL reconstructed group [43]. In addition, both the
During the last few years, the scientific community has
reconstructed leg of the ACL reconstructed group and the
given more attention to the role of the internal-external
deficient leg of the ACL-deficient group demonstrated signif-
rotation of the knee joint. There is a lot of work in this
icantly larger tibial rotation values than the healthy control.
area from very important centres [3,37—40] which have
Subsequently, we performed a follow-up evaluation [44]
influenced significantly the reconstruction of the ACL. Our
in nine BPTB reconstructed subjects that participated in this
investigations have examined knee joint rotational move-
study [43] and examined them for both the aforementioned
ment patterns during high- and low-demanding activities
high-demanding activities [42,43]. We found that tibial rota-
in ACL reconstructed patients with a BPTB or a hamstrings
tion remained significantly excessive even 2 years after the
graft, using gait analysis. In our first study, we examined
reconstruction. Thus, we questioned whether the configura-
13 ACL-deficient patients, 21 BPTB reconstructed patients
tion and placement of the BPTB graft in the femur had an
and 10 healthy matched controls during walking [41]. We
effect on rotational knee kinematics and we tried to identify
found that during this low-demanding activity, the surgi-
if a more horizontal placement of the femoral tunnel can
cal reconstruction with a BPTB graft restores tibial rotation
restore rotational kinematics, during these activities. We
to normal levels. Next, we wanted to identify if this was
evaluated 10 patients BPTB reconstructed with the femoral
also the case in a higher demanding activity, like descending
tunnel in the 11-o’clock position and 10 patients with the
stairs and subsequent pivoting [42] (Fig. 1). We evaluated 18
femoral tunnel in the 10-o’clock position [45]. We noticed
BPTB reconstructed patients 12 months postoperatively and
that positioning the tunnel at 10-o’clock resulted in slightly
15 controls. We found that the tibial rotation during the piv-
decreased rotation values that may have a clinical relevance
oting period was significantly larger in the ACL reconstructed
but did not show a statistical significance.
leg when was compared to the contralateral intact leg and
Following our research work with the BPTB graft, it was
the healthy control. To verify these findings, we examined
logical to question if tibial rotation will remain excessive if
11 BPTB reconstructed, 11 ACL-deficient patients and 11

Figure 1 A patient descending the stairway. The descending period was concluded upon initial foot contact with the ground.
Following foot contact, the subjects were instructed to pivot on the landing leg at 90 degrees and walk away from the stairway.
While pivoting, the contralateral leg was swinging around the body (as it was coming down from the stairway) and the trunk was
oriented perpendicularly to the stairway.

Figure 2 A patient jumping off the platform and land with both feet on the ground. Following foot contact, the subjects
pivot (externally rotate) on the right or left (ipsilateral) leg at 90 degrees and walk away from the platform. While pivoting,
the contralateral leg is swinging around the body and the trunk is oriented perpendicularly to the platform.
S122 A.D. Georgoulis et al.

a quadrupled hamstrings graft (semitendinous and gracilis; ing procedure, it seems promising towards the consensus
ST/G) was used. We examined 11 ST/G and 11 BPTB recon- effort of the complete restoration of abnormal tibial rota-
structed patients along with 11 healthy controls [46], during tion. However, these new techniques should be rigorously
landing with subsequent pivoting. We found significantly evaluated in terms of in vivo biomechanics and relevant long
increased tibial rotation in both ACL reconstructed groups term results are necessary to support its effectiveness.
when compared with the healthy controls. To verify our
findings, we performed an additional experiment where we
evaluated 11 ST/G reconstructed patients, 9 months after Gait variability after ACL injury and reconstruction
the surgery and 11 healthy controls during descending and
subsequent pivoting [47]. Our results also showed that the Recently a new methodology has been developed which
ST/G reconstruction did not restore excessive tibial rotation offers a more holistic approach concerning the study of gait.
to normal healthy levels. We expected better results from This approach is based on the fact that walking is a rhythmic
the ST/G graft because it has been demonstrated in several activity. The legs continuously oscillate forward and back-
studies [48] that this graft has mechanical properties similar ward generating movement. However, a closer examination
to those of the ACL. It also provides a two-stripe replace- reveals that each step is not identical to the previous or
ment graft that may better approximate the function of the to the next one (Fig. 3). These variations that exist among
two-bundle ACL. subsequent strides are intrinsic deriving from the underlying
Our results were in agreement with recent dynamic mechanisms that produce gait [60,61].
radiostereometric analysis technique (dRSA) [49] and MRI Accordingly, variations exist in all human rhythmic func-
[50] studies. Brandsson et al. [49] using a dRSA system found tions (i.e. secretion of the hormones, bearing of the heart).
that one year after BPTB reconstruction, tibial rotation was Interestingly, the concept of studying variability has been
not significantly different when compared with the preoper- first applied in domains such as endocrinology cardiology
ative measurements. In addition, Logan et al. [50] showed and neurology, providing useful information for the func-
with an ‘‘open-access’’ MRI system and during a dynamic tion of human body [62—64]. It is remarkable that in some
weight-bearing activity, that tibiofemoral kinematics are cases changes in variability have been found to be predictive
not restored in ACL reconstructed patients with hamstrings, of subsequent clinical changes (i.e. epileptic seizure) [63].
even though sagittal laxity is restored to normative val- Consequently, new theories have been proposed in order to
ues. assess and explain the function of human body [65,66].
In summary, our research work has showed increased Concerning human movement, Stergiou et al. [66] devel-
rotation after ACL reconstruction in activities that are more oped the ‘‘optimal amount of movement variability’’
demanding than walking and involve both anterior and rota- proposition. According to this proposition, under healthy
tional loading of the knee (pivoting). These findings persist conditions, each motor task is characterized by an optimal
regardless of autograft selection. Restore of tibial rotation amount of variability which provides the human body with
is of great importance, as studies have shown [51] that flexibility, adaptability and the capacity to respond to unpre-
sagittal plane knee joint forces cannot rupture the ACL dur- dictable stimuli and stresses and environmental demands.
ing sidestep cutting, and valgus-rotational loading seems to The achievement of this optimal variability is desired dur-
be the most likely injury mechanism. In addition, exces- ing human motor development and motor learning. On the
sive tibial rotation may cause abnormal loading of cartilage contrary, aging and disease are characterized by altered
areas which are not commonly loaded in the healthy knee (either increased or decreased) variability and are associ-
and longitudinally can lead to osteoarthritis [52,53]. The ated with diminished flexibility and capability to respond to
improvement and development of new surgical techniques, stimuli. This approach has been used to examine human gait
that can replicate better the actual anatomy of the nat- after ACL rupture [67—69]. Actually the authors examined
ural ACL, like the double-bundle (DB) ACL reconstruction, how knee flexion-extension changes over time over multiple
seems to be a way to address the problem of excessive tib- footfalls.
ial rotation. Many colleagues have described the details of It was observed that when compared to a healthy con-
this technique [54—59]. Although it is a technically demand- trol knee, the ACL-deficient knee exhibits decreased gait

Figure 3 In this graph, knee flexion-extension is plotted versus angular velocity. Each trajectory corresponds to one gait cycle.
Trajectories do not overlap revealing that variations exist from one stride to the next.
Biomechanics in ACL injury and reconstruction S123

Figure 4 Schematic representation of the decreased gait variability encountered after ACL injury. A and C represent knee flexion-
extension versus time over multiple footfalls for a healthy and an ACL-deficient knee, respectively. In the B and D graphs, the knee
flexion-extension time series are plotted versus angular velocity. It can be noticed that there is more overlapping between the
trajectories in the ACL-deficient knee, implying decreased gait variability.

variability [69]. This indicates that in the ACL-deficient Gait variability during backward walking
knees, subsequent steps are more similar to each other
than in healthy knees (Fig. 4). This could be due to the Gait variability can also be used to assess the outcome of
loss of the mechanical restraint or of the proprioceptive rehabilitation protocols after ACL injury. Backward walking
input provided by the ACL [70—74]. This decreased gait vari- (BW) is part of rehabilitation programs [80]. Physical ther-
ability indicates that a patient with ACL deficiency is more apists use BW since this task was proved to strength the
‘‘careful’’ in the way he or she walks in order to elimi- hamstring muscles [81,82] and this can improve the dynamic
nate any extra movements, exhibiting an increased rigidity knee joint stability of ACL-deficient patients. Apart from
in movement patterns. According to the optimal amount of rehabilitation, BW is used for injury prevention and training
movement variability proposition [66], these changes are [83]. This is because many sports such as soccer, football,
associated with decreased flexibility and responsiveness to basketball and tennis incorporate backward locomotion dur-
environmental demands, leading possibly to injury and the ing competition.
development of future pathology. We investigated if ACL deficiency affects gait variability
It was assumed that ACL reconstruction could restore during BW by comparing a group of ACL-deficient patients
gait variability. However, studies have shown that gait to a matched control group of healthy individuals. Both
variability is greater when compared to a healthy knee, knees of the ACL-deficient patients showed a more rigid
2 years after ACL reconstruction using either a BPTB or a walking pattern as compared to healthy controls. The con-
hamstrings autograft, which indicates decreased flexibil- tralateral intact knee of ACL-deficient patients showed even
ity and adaptability to stimuli and stresses [75,76]. This more rigid walking pattern as compared to the ACL-deficient
could be due to the altered muscle activity found in ACL knee. These data could imply diminished functional respon-
reconstructed limbs, which may derive from the altered siveness to the environmental demands for both knees of
proprioceptive input [77,78]. Thus, the ACL reconstructed ACL-deficient patients, which may result in knees more sus-
patients exhibit greater divergence in the movement tra- ceptible to injury.
jectories. This could signify that someone who knows that The results for variability in ACL-deficient patients walk-
the ACL is reconstructed feels ‘‘secure’’ to increase and ing backward seem to be similar to the results presented
add extra movement. However, because the innate pro- for walking forward [69]. Therefore, the ‘‘rigidity’’ that
prioceptive channels are missing, gait variability and the was noticed both during forward and backward walking can
function of the knee are not restored to normative lev- be related to the ACL deficiency and indicates that these
els. patients have less capability to respond to different pertur-
In addition alterations in gait variability were found in bations and to adapt to the changing environment.
the contralateral intact knee verifying the fact that adapta-
tions do exist in both limbs ACL reconstruction also affected
the structure of gait [76]. This supports previous studies that Neuromuscular control after ACL injury and
have identified bilateral lower extremity accommodations in reconstruction
gait biomechanics and muscular performance in ACL recon-
structed patient [79]. It should be noted that although the Muscle strength after ACL injury and
typical clinical tests (i.e. Lysholm score, IKDC) were nearly reconstruction
normal in all cases, the study of gait variability showed that
the proper function of the knee was not fully restored after
One of the most important adaptations after ACL injury is
ACL reconstruction. This indicates that this method is very
the thigh muscle strength deficit [84,85]. One of the most
sensitive and could prove to be very helpful in the assess-
common used tools for a highly reliable single-joint eval-
ment of various conditions as is has already been done in
uation is the isokinetic dynamometry [86—88]. The most
other medical domains.
common parameters that have been used in isokinetic eval-
S124 A.D. Georgoulis et al.

uation are work per unit, isokinetic curves and mainly the studies exist in the literature that documents the effect of
peak torque value [88—90]. ACL reconstruction with BPTB or hamstrings, on the donor-
In a study of our lab it has been noticed that after ACL site muscle’s EMD. In our first study, we evaluated 17 ACLR
rupture quadriceps and hamstring strength deficits exist patients with a BPTB autograft, 2 years after the reconstruc-
and there are numerous factors that are responsible for tion [104] under maximally explosive isometric contractions.
this [91]. After ACL rupture quadriceps muscle strength is We recorded the surface electromyographic (EMG) activity
decreased due to the loss of afferent reaction from the of rectus femoris (RF) and vastus medialis (VM). We found
ACL to gamma motor neurons [92]. The ACL rupture can that harvesting the medial third of the patellar tendon did
result in ‘‘quadriceps avoidance’’ gait patterns, which has not significantly alter the EMD of the knee extensor muscles.
been explained like a compensator mechanism for prevent- In our second study [105], we evaluated 12 ACLR patients
ing anterior sublaxation [93,94]. Hamstring muscle firing with an ST/G autograft and 12 healthy controls, using the
pattern changes, in an attempt to counteract these ante- same methodology and recording the ST and the biceps
rior shear forces. Specifically, it has been shown that after femoris (BF) muscles. Our statistical comparisons revealed
ACL rupture physiological modifications are developed with significant increases of the EMD of the ACLR knee for both
the intention to activate hamstrings for diminishing shear investigated muscles.
forces during knee loading [95]. Strength deficits after ACL The EMD measurement is of great functional impor-
rupture are time-dependent and quadriceps deficit persists tance, because regardless of the contractile ability of the
longer than hamstrings’ [91]. muscles, alterations in the EMD of the quadriceps or ham-
Imbalance of the knee muscle strength, between dif- strings muscle-tendon unit could compromise knee integrity
ferent muscle groups, has also been identified after ACL or impair performance by modifying the transfer time of
reconstruction. Failure to prevent or to effectively treat muscle tension to the bones. Our results suggested an
this imbalance may alter the patient’s functional recov- impairment of neuromuscular control at the knee flexors
ery [96] and predispose patients to re-rupture. Different after ACL surgery. However, further longitudinal investiga-
strength deficits have been reported after different graft tion is required to identify how the EMD is tolerated by the
types [88,97], which complicate the decision-making in central nervous system and if the increased hamstrings EMD
terms of either the type of graft to use or the focus of can influence patients’ optimal sports performance exposing
appropriate rehabilitation [98]. them to increased possibility of knee re-injury.
The achievement of muscle strength balance of lower
extremities may be one of the most important factors for
returning to pre-injury activity levels [96]. Except from The influence of metabolic fatigue on
the surgery itself, the muscular recovery after an ACL neuromuscular function in ACL reconstructed
reconstruction may be affected by numerous factors. The athletes
preoperative muscle strength [99], the time between injury
and reconstruction [100] and the pre- and post-surgery reha- ACL rupture is associated with altered neuromuscular
bilitation [101] are some of them. function as revealed by diminished EMG activity of the
Quadriceps strength weakness has been noticed after quadriceps and increased or earlier EMG activity of the
harvesting the BPTB autograft and hamstring muscle weak- biceps femoris during walking and running [106,107]. It has
ness after harvesting the HST autograft [97]. Muscle function been demonstrated that ACL reconstruction re-establishes
may also be modified due to the attenuation of the gamma EMG activation levels of the operated leg towards norma-
loop function caused from the ACL injury, which is not tive values during low demand activity such as walking and
restored after the ACL reconstruction. It is documented that jogging [108,109]. However the effect of metabolic fatigue
ACL mechanoreceptors play an important role in enhancing on EMG activation levels has not been tested. This is impor-
the activity of gamma motor neurons contributing to a nor- tant because fatigue is considered to have a cumulative
mal muscle function [92]. It is of crucial importance that, negative effect, resulting in hazardous movement strategies
before returning to sport activities after ACL reconstruction, and that knee injuries tend to occur at the later stages of
muscle strength deficits have to be diminished. For that rea- a game where there is accumulation of metabolic fatigue
son, rehabilitation after ACL reconstruction must focus on [110].
muscle strength recovery in conjunction with a plethora of Our first study examined the effect of metabolic fatigue
criteria [96]. on EMG activation levels in ACL reconstructed amateur soc-
cer players with a BPTB autograft and demonstrated that
metabolic fatigue had a negative effect on EMG activa-
Neuromuscular control in terms of tion levels of VL muscle of the operated leg [111] (Fig. 5).
electromechanical delay (EMD) in ACL Fatigue was verified with measurements of blood lactate and
reconstructed patients metabolic data [111] simulating conditions that are present
in sporting events. Our subsequent study demonstrated that
However, some researchers have suggested that the actual high intensity activities are required to reveal deficits of the
effectiveness of the muscles to provide mechanical response operated leg since during low demand activities there are no
and protection under real-life situations can be revealed differences in EMG activation levels between the operated,
only with the measurement of the time delay between the contralateral intact and control leg [112]. This study fur-
onset of muscle stimulation by the alpha motoneuron to ther demonstrated that similar levels of metabolic fatigue
the development of torque at a given joint [102,103]. This resulted in increased EMG activity for the control and intact
is referred as electromechanical delay (EMD) [102]. Few leg but not for the operated leg [112]. An impaired response
Biomechanics in ACL injury and reconstruction S125

Figure 5 a: athlete performing a test on a treadmill to determine intensities for the subsequent running exercises; b: the EMG
transmitter was placed behind the athletes back. EMG traces were collected from vastus lateralis and biceps femoris bilaterally; c:
athlete running on treadmill, with simultaneous collection of metabolic and EMG data.

of the operate leg under accumulation of metabolic fatigue attachments for a natomic reconstruction: a cadaveric dissec-
has been hypothesized [111]. tion and radiographic study. Arthroscopy 2006;22(9):984—92.
Endurance training following ACL reconstruction and [4] Zantop T, Herbort M, Raschke MJ, Fu FH, Petersen W. The
prior return to high intensity sports may enhance the role of the anteromedial and posterolateral bundles of the
response of the operated leg as may delay the occurrence anterior cruciate ligament in anterior tibial translation and
internal rotation. Am J Sports Med 2007;35(2):223—7.
of fatigue but this hypothesis remains to be tested [111].
[5] Girgis FG, Marshall JL, Monajem A. The cruciate ligaments
Furthermore, conditions simulating metabolic fatigue under of the knee joint: anatomical, functional and experimental
‘‘field’’ settings may be necessary to reveal deficits in neu- analysis. Clin Orthop Relat Res 1975;106:216—31.
romuscular function of ACL reconstructed athletes. [6] Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu
FH. The effectiveness of reconstruction of the anterior cruci-
Conclusion ate ligament with hamstrings and patellar tendon: a cadaveric
study comparing anterior tibial and rotational loads. J Bone
Joint Surg Am 2002;84:907—14.
Clinical knee joint biomechanics are impaired after ACL [7] Paessler HH, Michel D. How new is the Lachman test? Am J
injury, in terms of kinematics and neuromuscular control. Sports Med 1992;20:95—8.
Current ACL reconstruction techniques do not seem to [8] Noulis G. Entorse du genou. Thèse no 142. Fac Med Paris
fully restore normal physiology of the movement. Excessive 1875:1—53.
tibial rotation is still present in high-demanding activi- [9] Arendt E, Agel J, Dick RW. Anterior cruciate ligament injury
ties and impairment of neuromuscular control may persist patterns among collegiate men and women. J Athl Train
even though muscle strength is reinstated. These abnor- 1999;34(2):86—92.
[10] Boden BP, Dean GS, Feagin Jr JA, Garrett Jr WE. Mech-
mal biomechanical patterns may lead to loading of cartilage
anisms of anterior cruciate ligament injury. Orthopedics
areas which are not commonly loaded in the healthy
2000;23(6):573—8.
knee and longitudinally can lead to osteoarthritis. Mus- [11] Cochrane JL, Lloyd DG, Buttfield A, Seward H, McGivern J.
cle imbalance can also influence patients’ optimal sports Characteristics of anterior cruciate ligament injures in Aus-
performance, exposing them to increased possibility of tralian Football. J Sci Med Sport 2007;10(2):96—104.
knee re-injury. In this review, our recommendations point [12] Griffin LY, Albohm MJ, Arendt EA, et al. Understanding and
towards further experimental work, in order to assist in preventing non-contact anterior cruciate ligament injuries:
the development of new surgical procedures (like DB ACL a review of the Hunt Valley II Meeting. Am J Sports Med
reconstruction) that could possibly replicate more closely 2005;34(9):1512—23.
the natural ACL anatomy and prevent future knee pathol- [13] Cerulli G, Benoit DL, Lamontagne M, Caraffa A, Liti A. In vivo
anterior cruciate ligament strain behaviour during a rapid
ogy.
deceleration movement: case report. Knee Surg Sports Trau-
matol Arthrosc 2003;11(5):307—11.
Conflict of interest statement [14] Dempsey AR, Lloyd DG, Elliott BC, Steele JR, Munro BJ. Chang-
ing sidestep cutting technique reduces knee valgus loading.
There is no conflict of interest. Am J Sports Med 2009;37(11):2194—200.
[15] Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention
of anterior cruciate ligament injuries in soccer: a prospective
References controlled study of proprioceptive training. Knee Surg Sports
Traumatol Arthrosc 1996;4(1):19—21.
[1] Amis A, Bull AMJ, Lie DT. Biomechanics of rotational instability [16] Hame SL, Oakes DA, Markolf KL. Injury to the anterior cruci-
and anatomic anterior cruciate ligament reconstruction. Oper ate ligament during alpine skiing: a biomechanical analysis
Tech Orthop 2005;15:29—35. of tibial torque and knee flexion angle. Am J Sports Med
[2] Petersen W, Zantop T. Anatomy of the anterior cruciate lig- 2002;30(4):537—40.
ament with regard to its two bundles. Clin Orthop Relat Res [17] Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finer-
2007;454:35—47. man GA, Slauterbeck JL. Combined knee loading states that
[3] Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, generate high anterior cruciate ligament forces. J Orthop Res
Bellier G, et al. Morphology of anterior cruciate ligament 1995;13(6):930—5.
S126 A.D. Georgoulis et al.

[18] Hewett TE, Myer GD, Kevin R, Ford KR. Prevention of Ante- cruciate ligament tears by magnetic resonance imaging and
rior Cruciate Ligament Injuries. Curr Womens Health Rep arthroscopy. Am J Sports Med 1993;21:551—7.
2001;1:218—24. [36] Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker
[19] Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric train- D, Coolican M. Bone bruises associated with ACL rup-
ing in female athletes. Decreased impact forces and increased ture: correlation with injury mechanism. Am J Sports Med
hamstring torques. Am J Sports Med 1996;24:765—73. 2008;36:927—33.
[20] Hewett TE, Riccobene JV, Lindenfeld TN, et al. The effect [37] Moisala AS, Järvelä T, Harilainen A, Sandelin J, Kannus P,
of neuromuscular training on the incidence of knee injury Järvinen M. The effect of graft placement on the clinical
in female athletes: a prospective study. Am J Sports Med outcome of the anterior cruciate ligament reconstruction:
1999;27:699—706. a prospective study. Knee Surg Sports Traumatol Arthrosc
[21] Knapik JJ, Bauman CL, Jones BH, et al. Preseason strength 2007;15(7):879—87.
and flexibility imbalances associated with athletic injuries in [38] Ochi M, Adachi N, Uchio Y, Deie M, Kumahashi N, Ishikawa
female collegiate athletes. Am J Sports Med 1991;19:76—81. M, et al. A minimum 2-year follow-up after selective antero-
[22] Alentorn-Geli E, Myer GD, Silvers HJ, Samitier ZG, Romero medial or posterolateral bundle anterior cruciate ligament
D, Lázaro-Haro C, et al. Prevention of non-contact anterior reconstruction. Arthroscopy 2009;25(2):117—22.
cruciate ligament injuries in soccer players. Part 2. A review [39] Biau DJ, Katsahian S, Kartus J, Harilainen A, Feller JA, Sajovic
of prevention programs aimed to modify risk factors and M, et al. Patellar tendon versus hamstring tendon autografts
to reduce injury rates. Knee Surg Sports Traumatol Arthrosc for reconstructing the anterior cruciate ligament: a meta-
2009;17:859—79. analysis based on individual patient data. Am J Sports Med
[23] Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi 2009;37(12):2470—8.
T, Garrett W, et al. Non-contact ACL injuries in female ath- [40] Branch TP, Browne JE, Campbell JD, Siebold R, Freedberg
letes: an International Olympic Committee current concepts HI, Arendt EA, et al. Rotational laxity greater in patients
statement. Br J Sports Med 2008;42:394—412. with contralateral anterior cruciate ligament injury than
[24] Wilkerson GB, Colston MA, Short NI, Neal KL, Hoewischer PE, healthy volunteers. Knee Surg Sports Traumatol Arthrosc
Pixley JJ. Neuromuscular changes in female collegiate ath- 2010;18(10):1379—84.
letes resulting from a plyometric jump-training program. J [41] Georgoulis AD, Papadonikolakis A, Papageorgiou CD, et al.
Athl Train 2004;39:17—23. Three-dimensional tibiofemoral kinematics of the anterior
[25] Chimera NJ, Swanik KA, Swanik CB, Straub SJ. Effects of cruciate ligament-deficient and reconstructed knee during
plyometric training on muscle-activation strategies and per- walking. Am J Sports Med 2003;31(1):75—9.
formance in female athletes. J Athl Train 2004;39:24—31. [42] Ristanis S, Giakas G, Papageorgiou CD, et al. The effects
[26] Pujol N, Blanchi MP, Chambat P. The incidence of anterior of anterior cruciate ligament reconstruction on tibial rota-
cruciate ligament injuries among competitive Alpine skiers: a tion during pivoting after descending stairs. Knee Surg Sports
25-year investigation. Am J Sports Med 2007;35(7):1070—4. Traumatol Arthrosc 2003;11(6):360—5.
[27] Stergiou N, Ristanis S, Moraiti C, Georgoulis AD. Tibial rotation [43] Ristanis S, Stergiou N, Patras K, et al. Excessive tibial rota-
in anterior cruciate ligament (ACL)-deficient and ACL- tion during high demanding activities is not restored by ACL
reconstructed knees: a theoretical proposition for the devel- reconstruction. Arthroscopy 2005;21(11):1323—9.
opment of osteoarthritis. Sports Med 2007;37(7):601—13. [44] Ristanis S, Stergiou N, Patras K, et al. Follow-up evaluation
[28] Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster 2 years after ACL reconstruction with a BPTB graft shows
MS. Function, osteoarthritis and activity after ACL-rupture: that excessive tibial rotation persists. Clin J Sports Med
11 years follow-up results of conservative versus recon- 2006;16(2):111—6.
structive treatment. Knee Surg Sports Traumatol Arthrosc [45] Ristanis S, Stergiou N, Siarava E, Ntoulia A, Mitsionis G,
2008;16(5):442—8. Georgoulis AD. Effect of femoral tunnel placement for recon-
[29] Feagin JA, Curl WW. Isolated tear of the anterior cru- struction of the anterior cruciate ligament on tibial rotation.
ciate ligament: 5-year follow-up study. Am J Sports Med J Bone Joint Surg Am 2009;91(9):2151—8.
1976;4:95—100. [46] Chouliaras V, Ristanis S, Moraiti C, Stergiou N, Geor-
[30] Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. goulis AD. Effectiveness of reconstruction of the anterior
Biomechanical analysis of human ligament grafts used in cruciate ligament with quadrupled hamstrings and bone-
knee-ligament repairs and reconstructions. J Bone Joint Surg patellar tendon-bone autografts: an in vivo study com-
Am 1984;66:344—52. paring tibial internal-external rotation. Am J Sports Med
[31] Jones RS, Nawana NS, Pearcy MJ, Learmonth DJ, Bicker- 2007;35(2):189—96.
staff DR, Costi JJ, et al. Mechanical properties of the [47] Georgoulis AD, Ristanis S, Chouliaras V, Moraiti C, Stergiou N.
human anterior cruciate ligament. Clin Biomech 1995;10(7): Tibial rotation is not restored after ACL reconstruction with
339—44. a hamstring graft. Clin Orthop Relat Res 2007;454:89—94.
[32] Paschos NK, Gartzonikas D, Barkoula N-M, Moraiti C, Paipetis [48] Rowden N, Sher D, Rogers G, et al. Anterior cruciate ligament
A, Matikas TE, et al. Cadaveric study of anterior cruciate graft fixation. initial comparison of patellar tendon and semi-
ligament failure patterns under uniaxial tension along the tendinosus autografts in young fresh cadavers. Am J Sports
ligament. Arthroscopy 2010;26(7):957—67. Med 1997;25:472—8.
[33] Sonnery-Cottet B, Lavoie F, Ogassawara R, Scussiato RG, [49] Brandsson S, Karlsson J, Sward L, et al. Kinematics and laxity
Kidder JF, Chambat P. Selective anteromedial bundle recon- of the knee joint after anterior cruciate ligament reconstruc-
struction in partial ACL tears: a series of 36 patients with tion. Pre- and postoperative radiostereometric studies. Am J
mean 24 months follow-up. Knee Surg Sports Traumatol Sports Med 2002;30(3):361—7.
Arthrosc 2010;18(1):47—51. [50] Logan CM, Williams A, Lavelle J, et al. Tibiofemoral
[34] Siebold R, Fu FH. Assessment and augmentation of kinematics following successful ACL reconstruction using
symptomatic anteromedial or posterolateral bundle dynamic multiple resonance imaging. Am J Sports Med
tears of the anterior cruciate ligament. Arthroscopy 2004;32(4):984—92.
2008;24(11):1289—98. [51] McLean SG, Huang X, Su A, Van Den Bogert AJ. Sagittal plane
[35] Spindler KP, Schils JP, Bergfeld JA, et al. Prospective study biomechanics cannot injure the ACL during sidestep cutting.
of osseous, articular, and meniscal lesions in recent anterior Clin Biomech 2004;19(8):828—38.
Biomechanics in ACL injury and reconstruction S127

[52] Lohmander LS, Ostenberg A, Englund M, Roos H. High preva- [71] Schutte MJ, Dabezies EJ, Zimny ML, Happel LT. Neural
lence of knee osteoarthritis, pain, and functional limitations anatomy of the human anterior cruciate ligament. J Bone
in female soccer players twelve years after anterior cruciate Joint Surg Am 1987;69:243—7.
ligament injury. Arthritis Rheum 2004;50(10):3145—52. [72] Courtney C, Rine RM, Kroll P. Central somatosensory changes
[53] Andriacchi TP, Briant PL, Bevill SL, Koo S. Rotational changes and altered muscle synergies in subjects with anterior cruci-
at the knee after ACL injury cause cartilage thinning. Clin ate ligament deficiency. Gait Posture 2005;25:69—74.
Orthop Relat Res 2006;442:39—44. [73] Di Fabio RP, Graf B, Badke MB, Breunig A, Jensen K. Effect
[54] Hantes ME, Liantsis AK, Basdekis GK, Karantanas AH, Christel of knee joint laxity on long-loop postural reflexes: evi-
P, Malizos KN. Evaluation of the bone bridge between the bone dence for a human capsular-hamstring reflex. Exp Brain Res
tunnels after anatomic double-bundle anterior cruciate liga- 1992;90:189—200.
ment reconstruction: a multidetector computed tomography [74] Georgoulis AD, Pappa L, Moebius U, Malamou-Mitsi V, Pappa
study. Am J Sports Med 2010;38(8):1618—25. S, Papageorgiou CO, et al. The presence of proprioceptive
[55] Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double mechanoreceptors in the remnants of the ruptured ACL as a
bundle ACL reconstruction can improve rotational stability. possible source of re-innervation of the ACL autograft. Knee
Clin Orthop Relat Res 2007;454:100—7. Surg Sports Traumatol Arthrosc 2001;9:364—8.
[56] Zantop T, Wellmann M, Fu FH, Petersen W. Tunnel position- [75] Moraiti CO, Stergiou N, Ristanis S, Vasiliadis HS, Patras
ing of anteromedial and posterolateral bundles in anatomical K, Lee C, et al. The effect of anterior cruciate ligament
anterior cruciate ligament reconstructions: anatomic and reconstruction on stride-to-stride variability. Arthroscopy
radiographic findings. Am J Sports Med 2008;36:65—72. 2009;25(7):742—9.
[57] Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior [76] Moraiti CO, Stergiou N, Vasiliadis VS, Motsis E, Georgoulis
cruciate ligament anatomy and function relating to anatom- AD. Anterior cruciate ligament reconstruction results in alter-
ical reconstruction. Knee Surg Sports Traumatol Arthrosc ations in gait variability. Gait Posture 2010;32(2):169—75.
2006;14:982—92. [77] Hiemstra LA, Webber S, MacDonald PB, Kriellars DJ. Ham-
[58] Colombet PD, Robinson JR. Computer assisted anatomic, strings and quadriceps strength balance in normal and
double-bundle anterior cruciate ligament reconstruction. hamstring anterior cruciate ligament-reconstructed subjects.
Arthroscopy 2008;24(10):1152—60. Clin J Sports Med 2004;14:274—80.
[59] Christel P, Sahasrabudhe A, Basdekis G. Anatomic double- [78] Nakamura N, Horibe S, Sasaki S, et al. Evaluation of
bundle anterior cruciate ligament reconstruction with active knee flexion and hamstring strength after anterior
anatomic aimers. Arthroscopy 2008;24(10):1146—51. cruciate ligament reconstruction using hamstring tendons.
[60] Stergiou N, Buzzi UH, Kurz MJ, et al. Nonlinear tools in Arthroscopy 2002;18:598—602.
human movement. In: Stergiou N, editor. Innovative analyses [79] Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Con-
of human movement. Champaign, IL: Human Kinetics Publ; tralateral limb strength deficits after anterior cruciate
2004. ligament reconstruction using a hamstring tendon graft. Clin
[61] Hausdorff JM, Peng CK, Ladin Z, Wei JY, Goldberger AL. Biomech 2007;22:543—50.
Is walking a random walk? Evidence for long-range cor- [80] Myer GD, Paterno MV, Ford KR, Hewett TE. Neuromuscular
relations in stride interval of human gait. J Appl Physiol training techniques to target deficits before return to sport
1995;78(1):349—58. after anterior cruciate ligament reconstruction. Review. J
[62] Kaplan DT, Furman MI, Pincus SM, et al. Aging and the com- Strength Cond Res 2008;22:987—1014.
plexity of cardiovascular dynamics. Biophys J 1991;59:945—9. [81] Winter DA, Pluck N, Yang JF. Backward walking: a simple
[63] Le Van Quyen M, Martinerie J, Navarro V, Boon P, D’Have M, reversal of forward walking? J Mot Behav 1989;21:291—305.
Adam C, et al. Anticipation of epileptic seizures from standard [82] Grasso R, Bianchi L, Lacquaniti F. Motor patterns for human
EEG recordings. Lancet 2001;357:183—8. gait: backward versus forward locomotion. J Neurophysiol
[64] Veldman RG, Frolich M, Pincus SM, Veldhuis JD, Roelfsema 1998;8:1868—85.
F. Growth hormone and prolactin are secreted more irreg- [83] Hooper TL, Dunn DM, Props JE, Bruce BA, Sawyer SF, Daniel
ularly in patients with Cushing’s disease. Clin Endocrinol JA. The effects of graded forward and backward walking on
2000;52(5):625. heart rate and oxygen consumption. J Orthop Sports Phys Ther
[65] Lipsitz LA, Goldberger AL. Loss of ‘complexity’ and aging. 2004;34:65—71.
Potential applications of fractals and chaos theory to senes- [84] Keays SL, Bullock-Saxton J, Keays AC. Strength and function
cence. JAMA 1992;267(13):1806—9. before and after anterior cruciate ligament reconstruction.
[66] Stergiou N, Harbourne RT, Cavanaugh JT. Optimal movement Clin Orthop 2000;373:174—83.
variability: a new theoretical perspective for neurologic phys- [85] Mattacola CG, Perrin DH, Gansneder BM, Gieck JH, Saliba EN,
ical therapy. J Neurol Phys Ther 2006;30(3):120—9. McCue FC. Strength, functional outcome, and postural sta-
[67] Stergiou N, Moraiti C, Giakas G, Ristanis S, Georgoulis AD. bility after anterior cruciate ligament reconstruction. J Athl
The effect of the walking speed on the stability of the anterior Train 2002;37:262—8.
cruciate ligament deficient knee. Clin Biomech (Bristol, Avon) [86] Ageberg E, Thomeé R, Neeter C, Silbernagel KG, Roos EM.
2004;19(9):957—63. Muscle strength and functional performance in patients with
[68] Georgoulis AD, Moraiti C, Ristanis S, Stergiou N. A novel anterior cruciate ligament injury treated with training and
approach to measure variability in the anterior cruciate surgical reconstruction or training only: a two- to five-year
ligament deficient knee during walking: the use of the follow-up. Arthritis Rheum 2008;59(12):1773—9.
approximate entropy in orthopaedics. J Clin Monit Comput [87] Almekinders LC, Oman J. Isokinetic muscle testing: is it clin-
2006;20(1):11—8. ically useful? J Am Acad Orthop Surg 1994;2:221—5.
[69] Moraiti C, Stergiou N, Ristanis S, Georgoulis AD. ACL defi- [88] Pua YH, Bryant AL, Steele JR, Newton RU, Wrigley TV. Isoki-
ciency affects stride-to-stride variability as measured using netic dynamometry in anterior cruciate ligament injury and
nonlinear methodology. Knee Surg Sports Traumatol Arthrosc reconstruction. Ann Acad Med Singapore 2008;37(4):330—40.
2007;15(12):1406—13. [89] Tsepis E, Vagenas G, Giakas G, Georgoulis A. Hamstring
[70] Schultz RA, Miller DC, Kerr CS, Micheli L. Mechanoreceptors in weakness as an indicator of poor knee function in ACL-
human cruciate ligaments. A histological study. J Bone Joint deficient patients. Knee Surg Sports Traumatol Arthrosc
Surg Am 1984;66:1072—6. 2004;12(1):22—9.
S128 A.D. Georgoulis et al.

[90] Eitzen I, Eitzen TJ, Holm I, Snyder-Mackler L, Risberg MA. technique and rehabilitation: an assessment of randomized
Anterior cruciate ligament-deficient potential copers and controlled trials. Arthroscopy 2009;25(6):653—85.
noncopers reveal different isokinetic quadriceps strength [102] Cavanagh PR, Komi PV. Electromechanical delay in human
profiles in the early stage after injury. Am J Sports Med skeletal muscle under concentric and eccentric contractions.
2010;38(3):586—93. Eur J Appl Physiol Occup Physiol 1979;42(3):159—63.
[91] Tsepis E, Vagenas G, Ristanis S, Georgoulis AD. Thigh muscle [103] Vos EJ, Harlaar J, van Ingen Schenau GJ. Electromechanical
weakness in ACL-deficient knees persists without structured delay during knee extensor contractions. Med Sci Sports Exerc
rehabilitation. Clin Orthop Relat Res 2006;450:211—8. 1991;23(10):1187—93.
[92] Konishi Y, Fukubayashi T, Takeshita D. Mechanism of quadri- [104] Georgoulis AD, Ristanis S, Papadonikolakis A, Tsepis E, Moe-
ceps femoris muscle weakness in patients with anterior bius U, Moraiti C, et al. Electromechanical delay of the knee
cruciate ligament reconstruction. Scand J Med Sci Sports extensor muscles is not altered after harvesting the patel-
2002;12(6):371—5. lar tendon as a graft for ACL reconstruction: implications
[93] Wexler G, Hurwitz D, Bush-Joseph CA, Andriacchi T, Bernard for sports performance. Knee Surg Sports Traumatol Arthrosc
Jr RB. Functional gait adaptations in patients with anterior 2005;13(6):437—43.
cruciate ligament deficiency over time. Clin Orthop Relat Res [105] Ristanis S, Tsepis E, Giotis D, Stergiou N, Cerulli G, Geor-
1998;348:166—75. goulis AD. Electromechanical delay of the knee flexor muscles
[94] Papadonikolakis A, Cooper L, Stergiou N, Georgoulis AD, Sou- is impaired after harvesting hamstring tendons for ante-
cacos PN. Compensatory mechanisms in anterior cruciate rior cruciate ligament reconstruction. Am J Sports Med
ligament deficiency. Knee Surg Sports Traumatol Arthrosc 2009;37(11):2179—86.
2003;11(4):235—43 [Epub 2003 Apr 17]. [106] Limbird TJ, Shiavi R, Frazer M, Borra H. EMG profiles of knee
[95] Krogsgaard MR, Dyhre-Poulsen P, Fischer-Rasmussen joint musculature during walking: changes induced by ante-
T. Cruciate ligament reflexes. J Electromyogr Kinesiol rior cruciate ligament deficiency. J Orthop Res 1988;6:630—8.
2002;12(3):177—82. [107] Kalund S, Sinkjaer T, Arendt-Nielsen L, Simonsen O. Altered
[96] Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. timing of hamstring muscle action in anterior cruciate liga-
Rehabilitation after anterior cruciate ligament reconstruc- ment deficient patients. Am J Sports Med 1990;18:245—8.
tion: criteria-based progression through the return-to-sport [108] Knoll Z, Kiss RM, Kocsis L. Gait adaptation in ACL deficient
phase. J Orthop Sports Phys Ther 2006;36(6):385—402. subjects before and after anterior cruciate ligament recon-
[97] Dauty M, Tortellier L, Rochcongar P. Isokinetic and ante- struction surgery. J Electromyogr Kinesiol 2004;14:287—94.
rior cruciate ligament reconstruction with hamstrings or [109] Lewek M, Rudolph K, Axe M, Snyder-Mackler L. The effect of
patella tendon graft: analysis of literature. Int J Sports Med insufficient quadriceps strength on gait after anterior cruciate
2005;26(7):599—606. ligament reconstruction. Clin Biomech 2002;17:56—63.
[98] Van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ. [110] Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D,
Evidence-based rehabilitation following anterior cruciate lig- Lázaro-Haro C, et al. Prevention of non-contact anterior cru-
ament reconstruction. Knee Surg Sports Traumatol Arthrosc ciate ligament injuries in soccer players. Part 1. Mechanisms
2010;18(8):1128—44. of injury and underlying risk factors. Knee Surg Sports Trau-
[99] Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength matol Arthrosc 2009;17:705—29.
is a significant predictor of knee function two years after [111] Patras K, Ziogas G, Ristanis S, Tsepis E, Stergiou N, Georgoulis
anterior cruciate ligament reconstruction. Br J Sports Med AD. High intensity running results in an impaired neuromus-
2009;43(5):371—6. cular response in ACL reconstructed individuals. Knee Surg
[100] Petersen W, Laprell H. Combined injuries of the medial collat- Sports Traumatol Arthrosc 2009;17:977—84.
eral ligament and the anterior cruciate ligament. Early ACL [112] Patras K, Ziogas G, Ristanis S, Tsepis E, Stergiou N, Georgoulis
reconstruction versus late ACL reconstruction. Arch Orthop AD. ACL reconstructed patients with a BPTB graft present
Trauma Surg 1999;119(5—6):258—62. an impaired vastus lateralis neuromuscular response during
[101] Andersson D, Samuelsson K, Karlsson J. Treatment of anterior high intensity running. J Sci Med Sport 2010 [Epub ahead of
cruciate ligament injuries with special reference to surgical print].