Eccentric Exercise as a Potent Prescription for Muscle Weakness After Joint Injury.

Lengthening contractions (i.e., eccentric contractions) are capable of uniquely triggering the nervous system and signaling pathways to promote tissue health/growth. This mode of exercise may be particularly potent for patients suffering from muscle weakness after joint injury. Here we provide a novel framework for eccentric exercise as a safe, effective mode of exercise prescription for muscle recovery.

Mechanisms of Arthrogenic Muscle Inhibition.

CONTEXT: Arthrogenic muscle inhibition (AMI) continues to be a limiting factor in joint rehabilitation as the inability to volitionally activate muscle significantly dampens recovery. New evidence acquired at higher brain centers and in clinical populations continues to reshape our perspective of what AMI is and how to treat it. This review aims to stimulate discussion about the far-reaching effects of AMI by exploring the interconnected pathways by which it evolves. OBJECTIVES: To discuss how reflexive inhibition can lead to adaptations in brain activity, to illustrate how changes in descending motor pathways limit our ability to contract muscle following injury, and to summarize the emerging literature on the wide-reaching effects of AMI on other interconnected systems. DATA SOURCES: The databases PubMed, SPORTDiscus, and Web of Science were searched for articles pertaining to AMI. Reference lists from appropriate articles were cross-referenced. CONCLUSION: AMI is a sequential and cumulative neurological process that leads to complex clinical impairments. Originating with altered afferent information arising from an injured joint, patients experience changes in afferent information, reflexive muscle inhibition, deficiencies in somatosensation, neuroplastic compensations in higher brain centers, and ultimately decreased motor output to the muscle surrounding the joint. Other aspects of clinical function, like muscle structure and psychological responses to injury, are also impaired and influenced by AMI. Removing, or reducing, AMI should continue to be a focus of rehabilitation programs to assist in the optimization of health after joint injury.

Alterations in Quadriceps Neurologic Complexity After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Traditionally, quadriceps activation failure after anterior cruciate ligament reconstruction (ACLR) is estimated using discrete isometric torque values, providing only a snapshot of neuromuscular function. Sample entropy (SampEn) is a mathematical technique that can measure neurologic complexity during the entirety of contraction, elucidating qualities of neuromuscular control not previously captured. OBJECTIVE: To apply SampEn analyses to quadriceps electromyographic activity in order to more comprehensively characterize neuromuscular deficits after ACLR. DESIGN: Cross-sectional. SETTING: Laboratory. PARTICIPANTS: ACLR: n = 18; controls: n = 24. INTERVENTIONS: All participants underwent synchronized unilateral quadriceps isometric strength, activation, and electromyography testing during a superimposed electrical stimulus. MAIN OUTCOME MEASURES: Group differences in strength, activation, and SampEn were evaluated with t tests. Associations between SampEn and quadriceps function were evaluated with Pearson product-moment correlations and hierarchical linear regressions. RESULTS: Vastus medialis SampEn was significantly reduced after ACLR compared with controls (P = .032). Vastus medialis and vastus lateralis SampEn predicted significant variance in activation after ACLR (r2 = .444; P = .003). CONCLUSIONS: Loss of neurologic complexity correlates with worse activation after ACLR, particularly in the vastus medialis. Electromyographic SampEn is capable of detecting underlying patterns of variability that are associated with the loss of complexity between key neurophysiologic events after ACLR.

Protracted alterations in muscle activation strategies and knee mechanics in patients after Anterior Cruciate Ligament Reconstruction.

PURPOSE: Altered quadriceps muscle activity can contribute to reduced ability of the muscle to quickly generate force and appropriately attenuate landing forces, exacerbating poor landing and movement strategies commonly seen after anterior cruciate ligament reconstruction (ACLR). The purpose was to evaluate if electromyographic (EMG) activity and knee biomechanics during a single-limb forward hop task are influenced by a history of ACLR. METHODS: Twenty-six individuals with a history of unilateral ACLR (age 20.2 ± 2.7 years, height 1.7 ± 0.1 m; weight 69.6 ± 12.4 kg; time from surgery, 2.9 ± 2.7 years; graft type, 21 bone-patellar-tendon bone, 5 hamstring) and 8 healthy controls (age 23.3 ± 1.8 years, height 1.7 ± 0.1 m; mass 66.3 ± 13.9 kg) volunteered. Sagittal plane knee kinetics and EMG of the vastus lateralis were synchronized and measured using a three-dimensional motion analysis system during a single-limb forward hop task. Mixed-effect models were used to assess the effect of group on kinetic and EMG variables. RESULTS: Kinetic outcomes (peak and rate of knee extension moment) and temporal muscle activity and activation patterns differed between the ACLR limb and healthy-control limb. Inter-limb asymmetries in the ACLR group were observed for all variables except EMG onset time; no limb differences were observed in the healthy cohort. CONCLUSION: Years after ACLR, persistent quadriceps functional deficits are present, contributing to altered neuromuscular control strategies during functional tasks that may increase the risk of reinjury. To counteract these effects, emerging evidence indicates that clinicians could consider the use of motor learning strategies to improve neuromuscular control after ACLR. LEVEL OF EVIDENCE: III.

The Immediate Effects of Transcranial Direct Current Stimulation on Quadriceps Muscle Function in Individuals With a History of Anterior Cruciate Ligament Reconstruction: A Preliminary Investigation.

CONTEXT: Altered quadriceps activation is common following anterior cruciate ligament reconstruction (ACLR), and can persist for years after surgery. These neural deficits are due, in part, to chronic central nervous system alterations. Transcranial direct current stimulation (tDCS) is a noninvasive modality, that is, believed to immediately increase motor neuron activity by stimulating the primary motor cortex, making it a promising modality to use improve outcomes in the ACLR population. OBJECTIVE: To determine if a single treatment of tDCS would result in increased quadriceps activity and decreased levels of self-reported pain and dysfunction during exercise. DESIGN: Randomized crossover design. SETTING: Controlled laboratory. PATIENTS: Ten participants with a history of ACLR (5 males/5 females, 22.9 [4.23] y, 176.57 [12.01] cm, 80.87 [16.86] kg, 68.1 [39.37] mo since ACLR). INTERVENTIONS: Active tDCS and Sham tDCS. MAIN OUTCOME MEASURES: Percentage of maximum electromyographic data of vastus medialis and lateralis, voluntary isometric strength, percentage of voluntary activation, and self-reported pain and symptom scores were measured. The 2 × 2 repeated-measures analysis of variance by limb were performed to explain the differences between time points (pre and post) and condition (tDCS and sham). RESULTS: There was a significant time main effect for quadriceps percentage of maximum electromyographic of vastus medialis (F9,1 = 11.931, P = .01) and vastus lateralis (F9,1 = 9.132, P = .01), isometric strength (F9,1 = 5.343, P = .046), and subjective scores for pain (F9,1 = 15.499, P = .04) and symptoms (F9,1 = 15.499, P = .04). Quadriceps percentage of maximum electromyographic, isometric strength, and voluntary activation showed an immediate decline from pre to post regardless of tDCS condition. Subjective scores improved slightly after each condition. CONCLUSIONS: One session of active tDCS did not have an immediate effect on quadriceps activity and subjective scores of pain and symptoms. To determine if tDCS is a valid modality for this patient population, a larger scale investigation with multiple treatments of active tDCS is warranted.

Protracted Cardiovascular Impairments After Anterior Cruciate Ligament Injury: A Critically Appraised Topic.

Clinical Scenario: Anterior cruciate ligament (ACL) tear is a devastating knee injury with negative long-term consequences, such as early-onset knee osteoarthritis, biomechanical compensations, and reduced physical activity. Significant reduction in physical activity is a powerful indicator of cardiovascular (CV) disease; therefore, those with a history of ACL injury may be at increased risk for CV disease compared with noninjured individuals. Focused Clinical Question: Do individuals with a history of ACL injury demonstrate negative CV changes compared with those without a history of ACL injury? Summary of Key Findings: Three articles met the inclusion criteria and investigated CV changes after ACL injury. Both cross-sectional studies compared participants with ACL injury with matched controls. Bell et al compared time spent in moderate to vigorous physical activity and step count, whereas Almeida et al compared maximum rate of oxygen consumption, ventilatory thresholds, isokinetic quadriceps strength, and body composition. Collectively, both quantitative studies found that individuals with a history of ACL injury had less efficient CV systems compared with matched controls and/or preoperative data. Finally, a qualitative study of 3506 retired National Football League athletes showed an increased rate of arthritis and knee replacement surgery after an ACL injury when compared with other retired National Football League members, in addition to a >50% increased rate of myocardial infarction. Clinical Bottom Line: A history of ACL injury is a source of impaired physical activity. Preliminary data indicate that these physical activity limitations negatively impair the CV system, and individuals with a history of ACL injury demonstrate lower maximum oxygen consumption, self-reported disability, and daily step count compared with noninjured peers. These complications support the need for greater emphasis on CV wellness. Strength of Recommendation: Consistent findings from 2 cross-sectional studies and 1 survey study suggest level IIB evidence to support that ACL injury is associated with negative CV health.

Examining the Relationship Between Neuroplasticity and Learned Helplessness After ACLR: Early Versus Late Recovery.

CONTEXT: Altered neural signaling is known to have a direct impact on psychological wellness. Therefore, disruptions in neural signaling after anterior cruciate ligament reconstruction may influence psychological dysfunction, in some cases manifesting as learned helplessness. Helplessness is a psychological paradigm that presents as altered neuromuscular control, reduced motivation, and psychological deficits. OBJECTIVES: The authors sought to evaluate the relationship between helplessness, neural activity, and quadriceps function at different time points after anterior cruciate ligament reconstruction. EVIDENCE ACQUISITION: Twenty-nine individuals with unilateral anterior cruciate ligament reconstruction were categorized into early group (<2 y, age: 19.13 [2.18] y; height: 1.77 [0.11] m; mass: 76.903 [11.87] kg) or late group (>2 y, age: 22 [23] y; height: 1.67 [0.07] m; mass: 65.66 [11.33] kg). Quadriceps function (activation and strength), spinal-reflexive and corticospinal excitability (active motor thresholds and motor evoked potentials), and helplessness were obtained. A principal component analysis was performed by group (early and late) to identify which factors of helplessness were most associated with neural activity and quadriceps function. Pearson product moment correlation analyses were performed by group to determine associations between individual components and main outcomes. EVIDENCE SYNTHESIS: In the early group, cognitive readiness was associated with quadriceps strength of the injured limb (r2 = .513, P = .004), and self-awareness/management was associated with motor threshold of the injured limb (r2 = .238, P = .05). In the late group, intrinsic helplessness was associated with motor output of injured limb (r2 = .653, P = .01). CONCLUSION: Helplessness is made up of several attributional constructs, which are altered at different phases of recovery. Helplessness constructs interact differently with neural activity and quadriceps function across time. These findings are preliminary and do not establish a causal link between neural alterations and learned helplessness. Future studies should serially evaluate both changes in neural activity and learned helplessness attributes throughout recovery.

Quadriceps muscle function following anterior cruciate ligament reconstruction: systemic differences in neural and morphological characteristics.

Quadriceps muscle dysfunction is common following anterior cruciate ligament reconstruction (ACLR). Data considering the diversity of neural changes, in-concert with morphological adaptations of the quadriceps muscle, are lacking. We investigated bilateral differences in neural and morphological characteristics of the quadriceps muscle in ACLR participants (n = 11, month post-surgery: 69.4 ± 22.4) compared to controls matched by sex, age, height, weight, limb dominance, and activity level. Spinal reflex excitability was assessed using Hoffmann reflexes (H:M); corticospinal excitability was quantified via active motor thresholds (AMT) and motor-evoked potentials (MEP) using transcranial magnetic stimulation. Cortical activation was assessed using a knee flexion/extension task with functional magnetic resonance imaging (fMRI). Muscle volume was quantified using structural MRI. Muscle strength and patient-reported outcomes were also collected. 2 × 2 RM ANOVAs were used to evaluate group differences. Smaller quadriceps muscle volume (total volume, rectus femoris, vastus medialis, and intermedius) and lower strength were detected compared to contralateral and control limbs. Individuals with ACLR reported higher levels of pain and fear and lower levels of knee function compared to controls. No differences were observed for H:M. ACLR individuals demonstrated higher AMT bilaterally and smaller MEPs in the injured limb, compared to the controls. ACLR participants demonstrated greater activation in frontal lobe areas responsible for motor and pain processing compared to controls, which were associated with self-reported pain. Our results suggest that individuals with ACLR demonstrate systemic neural differences compared to controls, which are observed concurrently with smaller quadriceps muscle volume, quadriceps muscle weakness, and self-reported dysfunction.

Examination of Knee Morphology After Secondary Ipsilateral ACL Injury Compared With Those That Have Not Been Reinjured: A Preliminary Study.

CONTEXT: Modifiable and nonmodifiable risk factors have been identified for sustaining a primary anterior cruciate ligament (ACL) injury; however, less research is available examining risk factors for a second injury. Identifying whether bony morphological factors are different (or more exaggerated) among those that experience a secondary ACL injury is critical to understanding if nonmodifiable risk factors are associated with a second injury. OBJECTIVE: To determine if bony morphology is different among those that experience a secondary ACL reinjury as compared with those that do not. DESIGN: Case-control. SETTING: University laboratory. PARTICIPANTS AND INTERVENTIONS: ACL participants were tracked after return to play following primary reconstruction, and if individuals experienced a second ipsilateral injury (ACLx2; n = 14, 8f/6m, 17.9 ± 4.0 y), the primary clinical MRI was analyzed for bony morphological risk factors. ACLx2 participants were matched to individuals (sex, age, height, graft, gender, and activity level) that had undergone reconstruction but did not experience reinjury (ACLx1, n = 14, 8f/6m, 18.7 ± 4.0 y). Ten controls were also enrolled (5m/5f, 20.8 ± 3.9 y) for the purposes of comparing the authors' ACL data against healthy knees. MAIN OUTCOME MEASURES: Lateral and medial posterior tibial slopes (LPTS, MPTS), notch shape index (NSI), and medial tibial plateau depth of concavity (MDC). RESULTS: All ACL-reconstructed patients (combined ACLx1 and ACLx2 group) had a steeper LPTS than controls (d = 0.87, 95% CI 0.11-1.60, P = .023); however, no difference in LPTS was found between ACLx1 and ACLx2 (P > .05). No differences in MPTS, NSI, and MDC were found between all ACL participants (combined ACLx2 and ACLx1) and controls or between ACLx1 and ACLx2 (P > .05). CONCLUSIONS: Compared to healthy individuals, a steeper LPTS is a common bony abnormality in all ACL-injured participants. Individuals that go on to experience a second ipsilateral ACL injury do not have more exaggerated bony morphology than those that do not suggesting that differences in modifiable risk factors at return to play may contribute to reinjury.

Shifting the Current Clinical Perspective: Isolated Eccentric Exercise as an Effective Intervention to Promote the Recovery of Muscle After Injury.

Eccentric exercise is able to mechanically engage muscle, initiating strain-sensing molecules that promote muscle recovery by inducing beneficial adaptations in neural activity and muscle morphology, 2 critical components of muscle function that are negatively altered after injury. However, due to misinterpreted mathematic modeling and in situ and in vitro stretch protocols, a dogma that exposing muscle to eccentric exercise is associated with injury has been perpetuated in the literature. In response, clinicians have been biased toward using concentric exercise postinjury to improve the recovery of muscle function. Unfortunately, this conventional approach to rehabilitation does not restore muscle function, and reinjury rates remain high. Here, the authors present experimental evidence and theoretical support for the idea that isolated eccentric exercise is ideally suited to combat muscle inhibition and muscle strains and is an attractive alternative to concentric exercise.

Pre-operative quadriceps activation is related to post-operative activation, not strength, in patients post-ACL reconstruction.

PURPOSE: Quadriceps activation failure is considered to contribute to the weakness that lingers following anterior cruciate ligament (ACL) reconstruction. Importantly, the impact of pre-operative quadriceps activation on post-operative quadriceps function is unknown. Understanding this relationship is clinically important; as the counteractive approach clinicians should employ pre-operatively to mitigate post-operative quadriceps weakness is unclear. Accordingly, the primary purpose of this study was to investigate the relationship between pre-operative quadriceps activation and post-operative quadriceps strength and activation. METHODS: Fifty-four individuals post-ACL injury reported for testing on two occasions: prior to surgery and post-surgery once they returned to activity. Quadriceps activation was assessed using the burst superimposition technique and quantified using the central activation ratio. Quadriceps strength was assessed using isometric contractions that were performed at 90° of knee flexion. Multiple linear regressions were utilized to detect the relationships between pre-operative activation and strength and post-operative activation and strength. RESULTS: Pre-operative activation was not associated with post-operative strength (R(2) = 0.064, P = 0.186). Pre-operative quadriceps activation and strength were associated with post-operative activation (R(2) = 0.383, P ≤ 0.001) and strength (R(2) = 0.465, P ≤ 0.001), respectively. CONCLUSIONS: Individuals with better pre-operative quadriceps activation demonstrated greater post-operative activation. Similarly, individuals with better pre-operative strength demonstrated better post-operative strength. Pre-operative quadriceps activation was not a predictor of post-operative strength. From a clinical perspective, our work indicates that clinicians should utilize therapies targeting both quadriceps activation and strength prior to ACL reconstruction in order to maximize these factors post-ACL reconstruction, as pre-operative activation and strength are related to post-operative activation and strength, respectively at return-to-activity.

Does concomitant meniscectomy or meniscal repair affect the recovery of quadriceps function post-ACL reconstruction?

PURPOSE: The purpose of this study was to determine the effect of concomitant meniscal surgery on the recovery of quadriceps activation and strength at a time when individuals return to sport following anterior cruciate ligament (ACL) reconstruction. METHODS: Forty-six individuals that were cleared for participation following ACL reconstruction were invited to participate in this study. Participants were placed into groups according to surgical reports (ACL-only, n = 24; meniscal repair, n = 12; meniscectomy, n = 10). Quadriceps strength was quantified using isokinetic and isometric measures. Isokinetic strength was collected at 60°/s in concentric mode. Isometric strength was collected at 90° of knee flexion. Quadriceps activation was assessed using the burst superimposition technique and quantified via the central activation ratio. One-way ANOVAs were utilized to detect whether differences existed in quadriceps activation and strength between groups. Where appropriate, post hoc Bonferroni multiple comparison procedures were used. RESULTS: Quadriceps activation (P = n.s.) and strength (isokinetic: P = n.s.; isometric: P = n.s.) were not different between groups. CONCLUSION: Concomitant meniscectomy or meniscal repair did not affect the recovery of quadriceps activation and strength at a time when individuals return to sport following ACL reconstruction. Though group differences in quadriceps function were not detected, all participants demonstrated levels of quadriceps activation failure that are below healthy individuals at a time when they were returned to sport. Given that persistent quadriceps activation failure is detrimental to knee function, rehabilitation protocols that target quadriceps activation failure should be developed and employed post-reconstruction.

Open-sourced semi-automatic program for ultrasound assessments of femoral trochlea cartilage health.

We developed an open-sourced program that accounts for the current limitations of B-mode ultrasound and extends the clinical utility of ultrasound for assessing femoral trochlear cartilage thickness. Images were collected on 18 patients with a history of knee surgery. By failing to account for ultrasound acoustics and beam refraction, cartilage thickness was underestimated by 26% and overestimated by 0-4%, respectively (p < 0.001). Comprehensive thickness measurements achieved by measuring the Euclidean distance between every point were significantly different than traditional single-location measurements or by using the area/length (p = 0.004-0.006). Sub-regions were significantly different than all whole regions of interest (p = 0.001-0.012).

Quadriceps muscle atrophy after non-invasive anterior cruciate ligament injury: evidence linking to autophagy and mitophagy.

Introduction: Anterior cruciate ligament (ACL) injury is frequently accompanied by quadriceps muscle atrophy, a process closely linked to mitochondrial health and mitochondria-specific autophagy. However, the temporal progression of key quadricep atrophy-mediating events following ACL injury remains poorly understood. To advance our understanding, we conducted a longitudinal study to elucidate key parameters in quadriceps autophagy and mitophagy. Methods: Long-Evans rats were euthanized at 7, 14, 28, and 56 days after non-invasive ACL injury that was induced via tibial compression overload; controls were not injured. Vastus lateralis muscle was extracted, and subsequent immunoblotting analysis was conducted using primary antibodies targeting key proteins involved in autophagy and mitophagy cellular processes. Results: Our findings demonstrated dynamic changes in autophagy and mitophagy markers in the quadriceps muscle during the recovery period after ACL injury. The early response to the injury was characterized by the induction of autophagy at 14 days (Beclin1), indicating an initial cellular response to the injury. Subsequently, at 14 days we observed increase in the elongation of autophagosomes (Atg4B), suggesting a potential remodeling process. The autophagosome flux was also augmented between 14- and 28 days (LC3-II/LC3-I ratio and p62). Notably, at 56 days, markers associated with the elimination of damaged mitochondria were elevated (PINK1, Parkin, and VDAC1), indicating a possible ongoing cellular repair and restoration process. Conclusion: These data highlight the complexity of muscle recovery after ACL injury and underscore the overlooked but crucial role of autophagy and mitophagy in promoting the recovery process.

Development of a Low-cost Epimysial Electromyography Electrode: A Simplified Workflow for Fabrication and Testing.

Electromyography (EMG) is a valuable diagnostic tool for detecting neuromuscular abnormalities. Implantable epimysial electrodes are commonly used to measure EMG signals in preclinical models. Although classical resources exist describing the principles of epimysial electrode fabrication, there is a sparsity of illustrative information translating electrode theory to practice. To remedy this, we provide an updated, easy-to-follow guide on fabricating and testing a low-cost epimysial electrode. Electrodes were made by folding and inserting two platinum-iridium foils into a precut silicone base to form the contact surfaces. Next, coated stainless steel wires were welded to each contact surface to form the electrode leads. Lastly, a silicone mixture was used to seal the electrode. Ex vivo testing was conducted to compare our custom-fabricated electrode to an industry standard electrode in a saline bath, where high levels of signal agreement (sine [intraclass correlation - ICC= 0.993], square [ICC = 0.995], triangle [ICC = 0.958]), and temporal-synchrony (sine [r = 0.987], square [r = 0.990], triangle [r= 0.931]) were found across all waveforms. Low levels of electrode impedance were also quantified via electrochemical impedance spectroscopy. An in vivo performance assessment was also conducted where the vastus lateralis muscle of a rat was surgically instrumented with the custom-fabricated electrode and signaling was acquired during uphill and downhill walking. As expected, peak EMG activity was significantly lower during downhill walking (0.008 ± 0.005 mV) than uphill (0.031 ± 0.180 mV, p = 0.005), supporting the validity of the device. The reliability and biocompatibility of the device were also supported by consistent signaling during level walking at 14 days and 56 days post implantation (0.01 ± 0.007 mV, 0.012 ± 0.007 mV respectively; p > 0.05) and the absence of histological inflammation. Collectively, we provide an updated workflow for the fabrication and testing of low-cost epimysial electrodes.

Beyond weakness: Exploring intramuscular fat and quadriceps atrophy in ACLR recovery.

Muscle weakness following anterior cruciate ligament reconstruction (ACLR) increases the risk of posttraumatic osteoarthritis (OA). However, focusing solely on muscle weakness overlooks other aspects like muscle composition, which could hinder strength recovery. Intramuscular fat is a non-contractile element linked to joint degeneration in idiopathic OA, but its role post-ACLR has not been thoroughly investigated. To bridge this gap, we aimed to characterize quadriceps volume and intramuscular fat in participants with ACLR (male/female = 15/9, age = 22.8 ± 3.6 years, body mass index [BMI] = 23.2 ± 1.9, time since surgery = 3.3 ± 0.9 years) and in controls (male/female = 14/10, age = 22.0 ± 3.1 years, BMI = 23.3 ± 2.6) while also exploring the associations between intramuscular fat and muscle volume with isometric strength. Linear mixed effects models assessed (I) muscle volume, (II) intramuscular fat, and (III) strength between limbs (ACLR vs. contralateral vs. control). Regression analyses were run to determine if intramuscular fat or volume were associated with quadriceps strength. The ACLR limb was 8%-11% smaller than the contralateral limb (p < 0.05). No between-limb differences in intramuscular fat were observed (p 0.091-0.997). Muscle volume but not intramuscular fat was associated with strength in the ACLR and control limbs (p < 0.001-0.002). We demonstrate that intramuscular fat does not appear to be an additional source of quadriceps dysfunction following ACLR and that muscle size only explains some of the variance in muscle strength.

Effect of eccentric strengthening after anterior cruciate ligament reconstruction on quadriceps strength.

CLINICAL SCENARIO: Interventions aimed at safely overloading the quadriceps muscle after anterior cruciate ligament (ACL) reconstruction are essential to reducing quadriceps muscle weakness that often persists long after the rehabilitation period. Despite the best efforts of clinicians and researchers to improve ACL rehabilitation techniques, a universally effective intervention to restore preinjury quadriceps strength has yet to be identified. A muscle's force-producing capacity is most optimal when an external force exceeds that of the muscle while the muscle lengthens. Hence, the potential to improve muscle strength by overloading the tissue is greater with eccentric strengthening than with concentric strengthening. Traditionally, the application of early postoperative high-intensity eccentric resistance training to the ACL-reconstructed limb has been contraindicated, as there is potential for injury to the ACL graft, articular cartilage, or surrounding soft-tissue structures. However, recent evidence suggests that the application of early, progressive, high-force eccentric resistance exercises to the involved limb can be used to safely increase muscle volume and strength in ACL-reconstructed individuals. As a result, eccentric strengthening may be another attractive alternative to traditional concentric strengthening to improve quadriceps strength after ACL reconstruction. FOCUSED CLINICAL QUESTION: In patients who have undergone ACL reconstruction, is there evidence to suggest that eccentric exercise positively affects postoperative quadriceps strength?

Fatigue's lack of effect on thigh-muscle activity in anterior cruciate ligament-reconstructed patients during a dynamic-landing task.

CONTEXT: As individuals returning to activity after anterior cruciate ligament reconstruction (ACLr) likely experience fatigue, understanding how fatigue affects knee-muscle activation patterns during sport-like maneuvers is of clinical importance. Fatigue has been suggested to impair neuromuscular control strategies. As a result, fatigue may place ACLr patients at increased risk of developing posttraumatic osteoarthritis (OA). OBJECTIVE: To determine the effects of fatigue on knee-muscle activity post-ACLr. DESIGN: Case control. SETTING: University laboratory. PARTICIPANTS: 12 individuals 7-10 mo post-ACLr (7 male, 5 female; age 22.1 ± 4.7 y; 1.8 ± 0.1 m; mass 77.7 ± 11.9 kg) and 13 controls (4 male, 9 female; age 22.9 ± 4.3 y; 1.7 ± 0.1 m; mass 66.9 ± 9.8 kg). INTERVENTIONS: Fatigue was induced via repetitive sets of double-leg squats (n = 8), which were interspersed with sets of single-leg landings (n = 3), until squats were no longer possible. MAIN OUTCOME MEASURES: 2 × 2 repeated-measures ANOVA was used to detect the main effects of group (ACLr, control) and fatigue state (prefatigue, postfatigue) on quadriceps:hamstring cocontraction index (Q:H CCI). RESULTS: All subjects demonstrated higher Q:H CCI at prefatigue compared with postfatigue (F(1,23) = 66.949, P ≤ .001). Q:H CCI did not differ between groups (F(1,23) = 0.599, P = .447). CONCLUSIONS: The results indicate that regardless of fatigue state, ACLr individuals are capable of restoring muscle-activation patterns similar to those in healthy subjects. As a result, excessive muscle cocontraction, which has been hypothesized as a potential mechanism of posttraumatic OA, may not contribute to joint degeneration after ACLr.