Can Biomechanical Testing After Anterior Cruciate Ligament Reconstruction Identify Athletes at Risk for Subsequent ACL Injury to the Contralateral Uninjured Limb?

Abstract

Background: Athletes are twice as likely to rupture the anterior cruciate ligament (ACL) on their healthy contralateral knee than the reconstructed graft after ACL reconstruction (ACLR). Although physical testing is commonly used after ACLR to assess injury risk to the operated knee, strength, jump, and change-of-direction performance and biomechanical measures have not been examined in those who go on to experience a contralateral ACL injury, to identify factors that may be associated with injury risk.

Purpose: To prospectively examine differences in biomechanical and clinical performance measures in male athletes 9 months after ACLR between those who ruptured their previously uninjured contralateral ACL and those who did not at 2-year follow-up and to examine the ability of these differences to predict contralateral ACL injury.

Study design: Case-control study; Level of evidence, 3.

Methods: A cohort of male athletes returning to level 1 sports after ACLR (N = 1045) underwent isokinetic strength testing and 3-dimensional biomechanical analysis of jump and change-of-direction tests 9 months after surgery. Participants were followed up at 2 years regarding return to play or at second ACL injury. Between-group differences were analyzed in patient-reported outcomes, performance measures, and 3-dimensional biomechanics for the contralateral limb and asymmetry. Logistic regression was applied to determine the ability of identified differences to predict contralateral ACL injury.

Results: Of the cohort, 993 had follow-up at 2 years (95%), with 67 experiencing a contralateral ACL injury and 38 an ipsilateral injury. Male athletes who had a contralateral ACL injury had lower quadriceps strength and biomechanical differences on the contralateral limb during double- and single-leg drop jump tests as compared with those who did not experience an injury. Differences were related primarily to deficits in sagittal plane mechanics and plyometric ability on the contralateral side. These variables could explain group membership with fair to good ability (area under the curve, 0.74-0.80). Patient-reported outcomes, limb symmetry of clinical performance measures, and biomechanical measures in change-of-direction tasks did not differentiate those at risk for contralateral injury.

Conclusion: This study highlights the importance of sagittal plane control during drop jump tasks and the limited utility of limb symmetry in performance and biomechanical measures when assessing future contralateral ACL injury risk in male athletes. Targeting the identified differences in quadriceps strength and plyometric ability during late-stage rehabilitation and testing may reduce ACL injury risk in healthy limbs in male athletes playing level 1 sports.

Clinical relevance: This study highlights the importance of assessing the contralateral limb after ACLR and identifies biomechanical differences, particularly in the sagittal plane in drop jump tasks, that may be associated with injury to this limb. These factors could be targeted during assessment and rehabilitation with additional quadriceps strengthening and plyometric exercises after ACLR to potentially reduce the high risk of injury to the previously healthy knee.

Registration: NCT02771548 (ClinicalTrials.gov identifier).

Keywords: anterior cruciate ligament reconstruction; biomechanics; contralateral knee; reinjury; return to play.

Figures

Figure 1.

Flow diagram of matching process for the study groups: contralateral injury and no contralateral injury. 3D, 3-dimensional; ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; RTP, return to play.

Figure 2.

Biomechanical differences on contralateral side during double-leg drop jump for the study groups: contralateral injury (bold image) as compared with no contralateral injury (blurred image). COM, center of mass; vGRF, vertical ground-reaction force.

Figure 3.

Vertical ground-reaction force on the contralateral side during first ground contact of double-leg drop jump for the study groups: contralateral injury (CI) and no contralateral injury (NCI; matched cohort). Top panel: mean and SD clouds for the CI (black) and NCI (blue) groups. Middle panel: SPM{t}, the t statistic as a function of time describing the difference between the groups. Bottom panel: effect size as a function of time, describing the magnitude of the effect. Shaded portions of the bottom panel indicate average Cohen d >0.5, with orange indicating medium effect size throughout those phases. ACL, anterior cruciate ligament; SPM, statistical parametric mapping.