Steadiness training improves the quadriceps strength and self-reported outcomes in persistent quadriceps weakness following nine months of anterior cruciate ligament reconstruction and failed conventional physiotherapy


      • Persistent quadriceps weakness can occur after anterior cruciate ligament rupture.
      • Conventional rehabilitation cannot revert the Persistent quadriceps weakness.
      • Force steadiness training with visual feedback improves extensor torque.
      • Force steadiness training with visual feedback improves self-reported outcomes.


      Persistent quadriceps weakness may occur after anterior cruciate ligament reconstruction, limiting the strength gain. However, steadiness strengthening might change the inability to gain strength. Hence, we determined whether strength training with force steadiness and visual biofeedback can improve knee quadriceps torque, self-reported pain and knee stability in patients with persistent quadriceps weakness after knee anterior cruciate ligament reconstruction.
      Twenty-five patients (aged 43.7 ± 12.2 years) with persistent quadriceps weakness following knee anterior cruciate ligament reconstruction and 34-weeks of physiotherapy performed unilateral strength training for both lower limbs. Four-weeks of conventional physiotherapy at week-30 were given, confirming the inability to gain torque. Then, steadiness training (isometric knee extension with visual biofeedback) was given for 7-weeks. Knee quadriceps peak torque, strength improvement, determination of responders to the intervention, coherence of strength gain between limbs, and self-reported outcomes (pain and knee stability) were obtained. Descriptive statistics and data inference using mixed-ANOVA, McNemar test, and χ2 test were described.
      Quadriceps torque in the reconstructed knee improved (98.2 ± 47.2–155.2 ± 78.9 Nm; p = 0.031) for most patients (84%). Nevertheless, the torque was lower than the healthy side maintaining asymmetry (155.2 ± 78.9 vs. 209.5 ± 101.8 Nm; p = 0.026). There was high (20%) and medium coherence (80%) between limbs. Knee stability and pain improved in 72% of the patients (p < 0.001).
      Steadiness training after anterior cruciate ligament reconstruction followed 9 months of surgery and failed conventional physiotherapy, improves the persistent weakness and self-reported outcomes, but gain strength was dissimilar between limbs.


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        • Alnahdi A.H.
        • Zeni J.A.
        • Snyder-Mackler L.
        Muscle impairments in patients with knee osteoarthritis.
        Sports Health. 2012; 4: 284-292
        • Anderson M.J.
        • Browning W.M.
        • Urband C.E.
        • Kluczynski M.A.
        • Bisson L.J.
        A systematic summary of systematic reviews on the topic of the anterior cruciate ligament.
        Orthop. J. Sports Med. 2016; 4 (2325967116634074)
        • Ardern C.L.
        • Taylor N.F.
        • Feller J.A.
        • Whitehead T.S.
        • Webster K.E.
        Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery.
        Am. J. Sports Med. 2013; 41: 1549-1558
        • Beck T.W.
        • Defreitas J.M.
        • Stock M.S.
        • Dillon M.A.
        Effects of resistance training on force steadiness and common drive.
        Muscle Nerve. 2011; 43: 245-250
        • Bodkin S.
        • Goetschius J.
        • Hertel J.
        • Hart J.
        Relationships of muscle function and subjective knee function in patients after ACL reconstruction.
        Orthop. J. Sports Med. 2017; 5 (2325967117719041)
        • Bodkin S.G.
        • Bruce A.S.
        • Hertel J.
        • Diduch D.R.
        • Saliba S.A.
        • Novicoff W.M.
        • Hart J.M.
        Visuomotor therapy modulates corticospinal excitability in patients following anterior cruciate ligament reconstruction: a randomized crossover trial.
        Clin. Biomech. (Bristol, Avon). 2021; 81105238
        • Cavanaugh J.T.
        • Powers M.
        ACL rehabilitation progression: where are we now?.
        Curr. Rev. Musculoskelet. Med. 2017; 10: 289-296
        • Charles D.
        • White R.
        • Reyes C.
        • Palmer D.
        A systematic review of the effects of blood flow restriction training on quadriceps muscle atrophy and circumference post ACL reconstruction.
        Int. J. Sports Phys. Ther. 2020; 15: 882-891
        • Chmielewski T.L.
        • Stackhouse S.
        • Axe M.J.
        • Snyder-Mackler L.
        A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture.
        J. Orthop. Res. 2004; 22: 925-930
        • Davies G.J.
        • McCarty E.
        • Provencher M.
        • Manske R.C.
        ACL return to sport guidelines and criteria.
        Curr. Rev. Musculoskelet. Med. 2017; 10: 307-314
        • De la Fuente C.
        • Silvestre R.
        • Baechler P.
        • Gemigniani A.
        • Grunewaldt K.
        • Vassiliu M.
        • Wodehouse V.
        • Delgado M.
        • Carpes F.P.
        Intrasession real-time ultrasonography feedback improves the quality of transverse abdominis contraction.
        J. Manipulative Physiol. Ther. 2020;
        • Del Vecchio A.
        • Casolo A.
        • Negro F.
        • Scorcelletti M.
        • Bazzucchi I.
        • Enoka R.
        • Felici F.
        • Farina D.
        The increase in muscle force after 4 weeks of strength training is mediated by adaptations in motor unit recruitment and rate coding.
        J. Physiol. Lond. 2019; 597: 1873-1887
        • Enoka R.M.
        • Farina D.
        Force steadiness: from motor units to voluntary actions.
        Physiology (Bethesda). 2021; 36: 114-130
        • Frank R.M.
        • Hamamoto J.T.
        • Bernardoni E.
        • Cvetanovich G.
        • Bach B.R.
        • Verma N.N.
        • Bush-Joseph C.A.
        ACL reconstruction basics: quadruple (4-Strand) hamstring autograft harvest.
        Arthrosc. Tech. 2017; 6: e1309-e1313
        • Gabler C.
        • Kitzman P.H.
        • Mattacola C.G.
        Targeting quadriceps inhibition with electromyographic biofeedback: a neuroplastic approach.
        Crit. Rev. Biomed. Eng. 2013; 41: 125-135
        • Gagnier J.J.
        • Kienle G.
        • Altman D.G.
        • Moher D.
        • Sox H.
        • Riley D.
        • CARE Group
        The CARE guidelines: consensus-based clinical case reporting guideline development.
        BMJ Case Rep. 2013; 2013
        • Gaveau V.
        • Priot A.-E.
        • Pisella L.
        • Havé L.
        • Prablanc C.
        • Rossetti Y.
        Paradoxical adaptation of successful movements: the crucial role of internal error signals.
        Conscious. Cogn. 2018; 64: 135-145
        • Gonzalo-Skok O.
        • Moreno-Azze A.
        • Arjol-Serrano J.L.
        • Tous-Fajardo J.
        • Bishop C.
        A comparison of 3 different unilateral strength training strategies to enhance jumping performance and decrease interlimb asymmetries in soccer players.
        Int. J. Sports Physiol. Perform. 2019; : 1256-1264
        • Hart J.M.
        • Pietrosimone B.
        • Hertel J.
        • Ingersoll C.D.
        Quadriceps activation following knee injuries: a systematic review.
        J. Athl. Train. 2010; 45: 87-97
        • Hart H.F.
        • Collins N.J.
        • Ackland D.C.
        • Crossley K.M.
        Is self-reported knee stability associated with symptoms, function, and quality of life in people with knee osteoarthritis after anterior cruciate ligament reconstruction?.
        Clin. J. Sport Med. 2020; 30: e134-e138
        • Herrington L.
        • Ghulam H.
        • Comfort P.
        Quadriceps strength and functional performance after anterior cruciate ligament reconstruction in professional soccer players at time of return to sport.
        J. Strength Cond. Res. 2021; 35: 769-775
        • Hewett T.E.
        • Webster K.E.
        • Hurd W.J.
        Systematic selection of key logistic regression variables for risk prediction analyses: a five-factor maximum model.
        Clin. J. Sport Med. 2019; 29: 78-85
        • Indorato D.
        • Sturgil R.
        An assessment of rehabilitation protocols following anterior cruciate ligament reconstruction: a systematic review.
        Rehabil. Process Outcome. 2016; 5: RPO.S40054
        • Jebb A.T.
        • Ng V.
        • Tay L.
        A review of key Likert scale development advances: 1995-2019.
        Front. Psychol. 2021; 12637547
        • Kean C.O.
        • Birmingham T.B.
        • Garland S.J.
        • Bryant D.M.
        • Giffin J.R.
        Minimal detectable change in quadriceps strength and voluntary muscle activation in patients with knee osteoarthritis.
        Arch. Phys. Med. Rehabil. 2010; 91: 1447-1451
        • Krishnan C.
        • Williams G.N.
        Factors explaining chronic knee extensor strength deficits after ACL reconstruction.
        J. Orthop. Res. 2011; 29: 633-640
        • Lastra A.
        Guia de rehabilitacion del ligamento cruzado anterior (LCA).
        • Lepley A.S.
        • Lepley L.K.
        Mechanisms of arthrogenic muscle inhibition.
        J. Sport Rehabil. 2021; 1–10
        • Lepley L.K.
        • Palmieri-Smith R.M.
        Quadriceps strength, muscle activation failure, and patient-reported function at the time of return to activity in patients following anterior cruciate ligament reconstruction: a cross-sectional study.
        J. Orthop. Sports Phys. Ther. 2015; 45: 1017-1025
        • Lepley A.S.
        • Gribble P.A.
        • Pietrosimone B.G.
        Effects of electromyographic biofeedback on quadriceps strength: a systematic review.
        J. Strength Cond. Res. 2012; 26: 873-882
        • Lepley A.S.
        • Gribble P.A.
        • Thomas A.C.
        • Tevald M.A.
        • Sohn D.H.
        • Pietrosimone B.G.
        Quadriceps neural alterations in anterior cruciate ligament reconstructed patients: a 6-month longitudinal investigation.
        Scand. J. Med. Sci. Sports. 2015; 25: 828-839
        • Lewek M.
        • Rudolph K.
        • Axe M.
        • Snyder-Mackler L.
        The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction.
        Clin. Biomech. (Bristol, Avon). 2002; 17: 56-63
        • Liu J.
        • Sheng Y.
        • Liu H.
        Corticomuscular coherence and its applications: a review.
        Front. Hum. Neurosci. 2019; 13: 100
        • Luchtmann M.
        • Firsching R.
        Central plasticity resulting from chronic low back pain in degenerative disorders of the spine.
        Neural Regen. Res. 2015; 10: 1234-1236
        • Lynch A.D.
        • Logerstedt D.S.
        • Axe M.J.
        • Snyder-Mackler L.
        Quadriceps activation failure after anterior cruciate ligament rupture is not mediated by knee joint effusion.
        J. Orthop. Sports Phys. Ther. 2012; 42: 502-510
        • Moreno-Azze A.
        • Arjol-Serrano J.L.
        • Falcón-Miguel D.
        • Bishop C.
        • Gonzalo-Skok O.
        Comparison of three eccentric overload training strategies on power output and interlimb asymmetry in youth soccer players.
        Int. J. Environ. Res. Public Health. 2021; 18: 8270
        • Nazari-Sharabian M.
        • Karakouzian M.
        Relationship between sunspot numbers and mean annual precipitation: application of cross-wavelet transform—a case study.
        J. 2020; 3: 67-78
        • Nuccio S.
        • Del Vecchio A.
        • Casolo A.
        • Labanca L.
        • Rocchi J.E.
        • Felici F.
        • Macaluso A.
        • Mariani P.P.
        • Falla D.
        • Farina D.
        • Sbriccoli P.
        Deficit in knee extension strength following anterior cruciate ligament reconstruction is explained by a reduced neural drive to the vasti muscles.
        J. Physiol. 2021; 599: 5103-5120
        • Palmieri-Smith R.M.
        • Thomas A.C.
        • Wojtys E.M.
        Maximizing quadriceps strength after ACL reconstruction.
        Clin. Sports Med. 2008; 27: vii-ix
        • Park S.H.
        • Casamento-Moran A.
        • Singer M.L.
        • Ernster A.E.
        • Yacoubi B.
        • Humbert I.A.
        • Christou E.A.
        Integration of visual feedback and motor learning: corticospinal vs. corticobulbar pathway.
        Hum. Mov. Sci. 2018; 58: 88-96
        • Pietrosimone B.G.
        • Lepley A.S.
        • Ericksen H.M.
        • Gribble P.A.
        • Levine J.
        Quadriceps strength and corticospinal excitability as predictors of disability after anterior cruciate ligament reconstruction.
        J. Sport Rehabil. 2013; 22: 1-6
        • Pietrosimone B.G.
        • Lepley A.S.
        • Ericksen H.M.
        • Clements A.
        • Sohn D.H.
        • Gribble P.A.
        Neural excitability alterations after anterior cruciate ligament reconstruction.
        J. Athl. Train. 2015; 50: 665-674
        • Pietrosimone B.
        • McLeod M.M.
        • Florea D.
        • Gribble P.A.
        • Tevald M.A.
        Immediate increases in quadriceps corticomotor excitability during an electromyography biofeedback intervention.
        J. Electromyogr. Kinesiol. 2015; 25: 316-322
        • Rice D.A.
        • McNair P.J.
        • Lewis G.N.
        Mechanisms of quadriceps muscle weakness in knee joint osteoarthritis: the effects of prolonged vibration on torque and muscle activation in osteoarthritic and healthy control subjects.
        Arthritis Res. Ther. 2011; 13: R151
        • Riesterer J.
        • Mauch M.
        • Paul J.
        • Gehring D.
        • Ritzmann R.
        • Wenning M.
        Relationship between pre- and post-operative isokinetic strength after ACL reconstruction using hamstring autograft.
        BMC Sports Sci. Med. Rehabil. 2020; 12: 68
        • Rush J.L.
        • Glaviano N.R.
        • Norte G.E.
        Assessment of quadriceps corticomotor and spinal-reflexive excitability in individuals with a history of anterior cruciate ligament reconstruction: a systematic review and meta-analysis.
        Sports Med. 2021; 51: 961-990
        • Semmler J.G.
        Motor unit synchronization and neuromuscular performance.
        Exerc. Sport Sci. Rev. 2002; 30: 8-14
        • Sonnery-Cottet B.
        • Saithna A.
        • Quelard B.
        • Daggett M.
        • Borade A.
        • Ouanezar H.
        • Thaunat M.
        • Blakeney W.G.
        Arthrogenic muscle inhibition after ACL reconstruction: a scoping review of the efficacy of interventions.
        Br. J. Sports Med. 2019; 53: 289-298
        • Stania M.
        • Król P.
        • Sobota G.
        • Polak A.
        • Bacik B.
        • Juras G.
        The effect of the training with the different combinations of frequency and peak-to-peak vibration displacement of whole-body vibration on the strength of knee flexors and extensors.
        Biol. Sport. 2017; 34: 127-136
        • Tracy B.L.
        • Enoka R.M.
        Steadiness training with light loads in the knee extensors of elderly adults.
        Med. Sci. Sports Exerc. 2006; 38: 735-745
        • Tsaopoulos D.E.
        • Baltzopoulos V.
        • Richards P.J.
        • Maganaris C.N.
        Mechanical correction of dynamometer moment for the effects of segment motion during isometric knee-extension tests.
        J. Appl. Physiol. 2011; 1985: 68-74
        • Turman K.A.
        • Diduch D.R.
        • Miller M.D.
        All-inside meniscal repair.
        Sports Health. 2009; 1: 438-444
        • Van Wyngaarden J.J.
        • Jacobs C.
        • Thompson K.
        • Eads M.
        • Johnson D.
        • Ireland M.L.
        • Noehren B.
        Quadriceps strength and kinesiophobia predict long-term function after ACL reconstruction: a cross-sectional pilot study.
        Sports Health. 2021; 13: 251-257
        • Vila-Chã C.
        • Falla D.
        Strength training, but not endurance training, reduces motor unit discharge rate variability.
        J. Electromyogr. Kinesiol. 2016; 26: 88-93
        • Ye X.
        • Beck T.W.
        • Wages N.P.
        Influences of dynamic exercise on force steadiness and common drive.
        J. Musculoskelet. Neuronal Interact. 2014; 14: 377-386
        • Zarzycki R.
        • Morton S.M.
        • Charalambous C.C.
        • Pietrosimone B.
        • Williams G.N.
        • Snyder-Mackler L.
        Athletes after anterior cruciate ligament reconstruction demonstrate asymmetric intracortical facilitation early after surgery.
        J. Orthop. Res. 2021; 39: 147-153