Science Meets Practice: What s missing in our assessment and treatment of muscle dysfunction after ACL injury?

Transcription

1 Science Meets Practice: What s missing in our assessment and treatment of muscle dysfunction after ACL injury? Speakers: Stephanie Di Stasi, PT, PhD, OCS Terry L. Grindstaff, PhD, PT, ATC Laura Schmitt PT, MPT, PhD APTA Combined Sections Meeting Sports Section Saturday, February 24, 2018: 8:00-10:00 AM New Orleans, LA Course Description: This Science Meets Practice session will focus on evidence-based assessment and treatment of muscle dysfunction following ACL injury and reconstruction. Four platform presenters will provide insights into contemporary research and then consider the implications of this work through a moderator-led case study discussion. Leading clinician scientists and researchers will discuss key elements of a comprehensive approach for muscle function assessment in clinical and research laboratory environments. Implications for effective treatment of muscle dysfunction will be deliberated in both the dialogues and panel sections. The session will conclude with audience questions and discussion with platform presenters and panel members. Course Learning Objectives: 1. Apply current research to ACL rehabilitation clinical cases. 2. Observe a clinical decision-making model to inform treatment selection based on relevant muscle function assessment methods used in individuals with ACL reconstruction 3. Select appropriate tests and measures that best discriminate between individuals who have successful and unsuccessful outcomes following ACL reconstruction. Session Outline: 00:00-00:05 Introduction and overview of session format 00:05-00:29 Presentation of 4 research abstracts related to muscle function in individuals with ACL injury 00:30-00:40 Moderator-led Q&A/summary of session (Di Stasi) 00:41-01:00 Case study presentation (Di Stasi) with application of current research from abstract presenters 01:00-01:22 Dialogue #1: Neuromuscular effects of ACL injury: why strength training alone is not enough (Grindstaff) 01:22-01:44 Dialogue #2: Weakness and altered biomechanics: evidence for the positive effects of strengthening (Schmitt) 01: Moderator-led Q&A/summary of session (Di Stasi)

2 Case Study Presentation (Di Stasi) 1. Present case and episode of care timeline (41 weeks, 26 visits) a. 15 y.o. female varsity basketball player s/p R ACL injury and medial meniscus tear (mid-october 2016) b. Single pre-op PT visit f/b ACLR with semitendinosus-gracilis autograft and meniscal repair 3 weeks post-injury c. Goal: run spring track, return to basketball next fall 2. Summary of impairments and functional limitations pre-aclr a. Precautions b. ROM, effusion, pain c. ADL biomechanics d. Muscle function: i. Quadriceps and hamstrings: peak MVIC, agonist/antagonist ratios (knee extensors/flexors),[1,6,9,14,15,18] ii. Triceps surae: standing heel rise test (max number of repetitions)[10,13] iii. Hip strength: hand held dynamometry, single leg bridge[4] 3. Describe the early phase (0-8 weeks) rehabilitation priorities to address muscle function impairments[1,15] a. High-load, protected range isotonics and isometrics b. High-intensity NMES c. High-volume/repetition muscle re-education activities 4. Panel question: What are the main considerations for muscle function testing within first 12 weeks post-aclr? How does this frame your patient education/discussion regarding POC and long-term RTS at this phase?[6,8,9,11,12,14,17,18,20] 5. 4 month RTS testing results and updates to muscle training interventions a. Describe the strength, power, and endurance training to address muscle impairments (12-24 weeks post-aclr)[1-5,7,9,16,18,19] i. PWB WB low-intensity plyometrics, return to running progression, agilities ii. Plyometric and agility progressions, power training 6. Panel question: How do you assess muscle function in the middle/late phases of rehabilitation? How do these data contribute to your RTS decisions?[8,11,12,14,17,18] 7. Describe transition to return-to-play preparation focused on muscle performance impairments[2,3,5,7,19] and 40 week post-op/discharge status a. High-intensity plyometrics b. Partner-opposed agilities and ball-handling c. Power and endurance training d. RTS testing outcomes, transition of care to ATC 8. Panel question: What other muscle function assessment or intervention techniques might you have incorporated in this patient s POC to optimize readiness to RTS?

3 References 1. Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop Sports Phys Ther Jul;42(7): doi: /jospt Epub 2012 Mar 8. PubMed PMID: ; PubMed Central PMCID: PMC Ageberg E, Thomeé R, Neeter C, Silbernagel KG, Roos EM. Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: a two to five-year followup. Arthritis Rheum Dec 15;59(12): doi: /art PubMed PMID: Arundale AJH, Cummer K, Capin JJ, Zarzycki R, Snyder-Mackler L. Report of the Clinical and Functional Primary Outcomes in Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary Prevention With and Without Perturbation Training 1 and 2 Years After ACL Reconstruction. Clin Orthop Relat Res Oct;475(10): doi: /s PubMed PMID: ; PubMed Central PMCID: PMC Bell DR, Trigsted SM, Post EG, Walden CE. Hip Strength in Patients with Quadriceps Strength Deficits after ACL Reconstruction. Med Sci Sports Exerc Oct;48(10): doi: /MSS PubMed PMID: Chmielewski TL, George SZ, Tillman SM, Moser MW, Lentz TA, Indelicato PA, Trumble TN, Shuster JJ, Cicuttini FM, Leeuwenburgh C. Low- Versus High-Intensity Plyometric Exercise During Rehabilitation After Anterior Cruciate Ligament Reconstruction. Am J Sports Med Mar;44(3): doi: / Epub 2016 Jan 21. PubMed PMID: Di Stasi SL, Logerstedt D, Gardinier ES, Snyder-Mackler L. Gait patterns differ between ACL-reconstructed athletes who pass return-to-sport criteria and those who fail. Am J Sports Med Jun;41(6): doi: / Epub 2013 Apr 5. PubMed PMID: ; PubMed Central PMCID: PMC Di Stasi S, Myer GD, Hewett TE. Neuromuscular training to target deficits associated with second anterior cruciate ligament injury. J Orthop Sports Phys Ther Nov;43(11): , A1-11. doi: /jospt Epub 2013 Oct 11. Review. PubMed PMID: ; PubMed Central PMCID: PMC Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med Jul;50(13): doi: /bjsports Epub 2016 May 9. PubMed PMID: ; PubMed Central PMCID: PMC Harkey MS, Luc-Harkey BA, Lepley AS, Grindstaff TL, Gribble P, Blackburn JT, Spang JT, Pietrosimone B. Persistent Muscle Inhibition after Anterior Cruciate Ligament Reconstruction: Role of Reflex Excitability. Med Sci Sports Exerc Dec;48(12): PubMed PMID: Hébert-Losier K, Wessman C, Alricsson M, Svantesson U. Updated reliability and normative values for the standing heel-rise test in healthy adults. Physiotherapy Dec;103(4): doi: /j.physio Epub 2017 Mar 21. PubMed PMID: Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC. Young Athletes With Quadriceps Femoris Strength Asymmetry at Return to Sport After Anterior Cruciate Ligament Reconstruction Demonstrate Asymmetric Single-Leg Drop-Landing Mechanics. Am J Sports Med Nov;43(11): doi: / Epub 2015 Sep 10. PubMed PMID:

4 12. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med Aug;50(15): doi: /bjsports Epub 2016 May 23. PubMed PMID: Olsson N, Karlsson J, Eriksson BI, Brorsson A, Lundberg M, Silbernagel KG. Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture. Scand J Med Sci Sports Feb;24(1): doi: /j x. Epub 2012 Jun 21.PubMed PMID: Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE. Strength Asymmetry and Landing Mechanics at Return to Sport after Anterior Cruciate Ligament Reconstruction. Med Sci Sports Exerc Jul;47(7): doi: /mss PubMed PMID: ; PubMed Central PMCID: PMC Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am Aug;77(8): PubMed PMID: Thomas AC, Villwock M, Wojtys EM, Palmieri-Smith RM. Lower extremity muscle strength after anterior cruciate ligament injury and reconstruction. J Athl Train Sep- Oct;48(5): doi: / PubMed PMID: ; PubMed Central PMCID: PMC Toole AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, Schmitt LC. Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs? J Orthop Sports Phys Ther Nov;47(11): doi: /jospt Epub 2017 Oct 7. PubMed PMID: Wellsandt E, Failla MJ, Snyder-Mackler L. Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther May;47(5): doi: /jospt Epub 2017 Mar 29. PubMed PMID: ; PubMed Central PMCID: PMC White K, Di Stasi SL, Smith AH, Snyder-Mackler L. Anterior cruciate ligament-specialized post-operative return-to-sports (ACL-SPORTS) training: a randomized control trial. BMC Musculoskelet Disord Mar 23;14:108. doi: / PubMed PMID: ; PubMed Central PMCID: PMC Zwolski C, Schmitt LC, Quatman-Yates C, Thomas S, Hewett TE, Paterno MV. The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction. Am J Sports Med Sep;43(9): doi: / Epub 2015 Jul 16. PubMed PMID:

5 Dialogue #1: Neuromuscular effects of ACL injury: why strength training alone is not enough (Grindstaff) Despite surgical intervention and rehabilitation 30-50% of individuals continue to have impairments and decreased function at return to sport 20-30% have reinjury within 2 years Quadriceps weakness Common impairment after knee joint injury Most severe immediately following injury or surgery Can persist beyond years after injury Quadriceps weakness causes9, 21, 23 Peripheral (muscle atrophy) 11, 16 Neurological (a.k.a. quadriceps inhibition) 8, 9, 13 o Spinal reflex excitability (more acute response) 7 o Corticomotor excitability (longer term) 2, 10, 12, 15, 20 Rehabilitation strategies can be optimized to target specific pathways6, 21, 23 Afferent pathways o TENS (sensory) o Cryotherapy o Joint mobilization 5 o Vibration17, 18 Efferent pathways o Biofeedback 19 o NMES o TMS o tdcs3, 24 Aggressive resistance training1, 14, 22 Rehabilitation exercise intensity may be too low to elicit substantial gains o Consider established training principles Known to alter corticomotor excitability in healthy individuals4, 25

6 References 1. Augustsson J. Documentation of strength training for research purposes after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013;21: Baumeister J, Reinecke K, Schubert M, Weiß M. Altered electrocortical brain activity after ACL reconstruction during force control. Journal of Orthopaedic Research. 2011;29: Chang W-J, Bennell KL, Hodges PW, et al. Addition of transcranial direct current stimulation to quadriceps strengthening exercise in knee osteoarthritis: A pilot randomised controlled trial. PLoS ONE. 2017;12:e Goodwill AM, Pearce AJ, Kidgell DJ. Corticomotor plasticity following unilateral strength training. Muscle Nerve. 2012;46: Grindstaff TL, Pietrosimone BG, Sauer LD, et al. Manual therapy directed at the knee or lumbopelvic region does not influence quadriceps spinal reflex excitability. Man Ther. 2014;19: Harkey MS, Gribble PA, Pietrosimone BG. Disinhibitory Interventions and Voluntary Quadriceps Activation: A Systematic Review. Journal of Athletic Training. 2014;49: Harkey MS, Luc BA, Lepley AS, et al. Persistent Muscle Inhibition after ACL Reconstruction: Role of Reflex Excitability. Med Sci Sports Exerc. 2016;48: Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010;45: Ingersoll CD, Grindstaff TL, Pietrosimone BG, Hart JM. Neuromuscular consequences of anterior cruciate ligament injury. Clin Sports Med. 2008;27: Kapreli E, Athanasopoulos S, Gliatis J, et al. Anterior Cruciate Ligament Deficiency Causes Brain Plasticity: A Functional MRI Study. The American Journal of Sports Medicine. 2009;37: Kuenze CM, Blemker SS, Hart JM. Quadriceps function relates to muscle size following ACL reconstruction. Journal of Orthopaedic Research. 2016;34: Kuenze CM, Hertel J, Weltman A, Diduch D, Saliba SA, Hart JM. Persistent Neuromuscular and Corticomotor Quadriceps Asymmetry After Anterior Cruciate Ligament Reconstruction. Journal of Athletic Training. 2015;50: Lepley AS, Gribble PA, Thomas AC, Tevald MA, Sohn DH, Pietrosimone BG. Quadriceps neural alterations in anterior cruciate ligament reconstructed patients: A 6- month longitudinal investigation. Scandinavian Journal of Medicine & Science in Sports. 2015;25: Lorenz DS, Reiman MP, Walker JC. Periodization: Current Review and Suggested Implementation for Athletic Rehabilitation. Sports Health: A Multidisciplinary Approach. 2010;2: Luc-Harkey BA, Harkey MS, Pamukoff DN, et al. Greater intracortical inhibition associates with lower quadriceps voluntary activation in individuals with ACL reconstruction. Experimental Brain Research. 2017;235: Norte GE, Knaus KR, Kuenze C, et al. MRI-Based Assessment of Lower Extremity Muscle Volumes in Patients Before and After ACL Reconstruction. Journal of Sport Rehabilitation. 2017; Pamukoff DN, Pietrosimone B, Lewek MD, et al. Whole-Body and Local Muscle Vibration Immediately Improve Quadriceps Function in Individuals With Anterior Cruciate Ligament Reconstruction. Archives of Physical Medicine and Rehabilitation. 2016;97: Pamukoff DN, Pietrosimone B, Ryan ED, Lee DR, Brown LE, Blackburn JT. Whole-Body Vibration Improves Early Rate of Torque Development in Individuals With Anterior

7 Cruciate Ligament Reconstruction. The Journal of Strength & Conditioning Research. 2017;31: Pietrosimone B, McLeod MM, Florea D, Gribble PA, Tevald MA. Immediate increases in quadriceps corticomotor excitability during an electromyography biofeedback intervention. Journal of Electromyography and Kinesiology. 2015;25: Pietrosimone BG, Lepley AS, Ericksen HM, Clements A, Sohn DH, Gribble PA. Neural Excitability Alterations After Anterior Cruciate Ligament Reconstruction. Journal of Athletic Training. 2015;50: Pietrosimone BG, McLeod MM, Lepley AS. A Theoretical Framework for Understanding Neuromuscular Response to Lower Extremity Joint Injury. Sports Health: A Multidisciplinary Approach. 2012;4: Reiman MP, Lorenz DS. Integration of strength and conditioning principles into a rehabilitation program. International Journal of Sports Physical Therapy. 2011;6: Rice DA, McNair PJ. Quadriceps Arthrogenic Muscle Inhibition: Neural Mechanisms and Treatment Perspectives. Seminars in Arthritis and Rheumatism. 2010;40: Vargas VZ, Baptista AF, Pereira GOC, et al. Modulation of isometric quadriceps strength in soccer players with transcranial direct current stimulation: a crossover study. The Journal of Strength & Conditioning Research. 2017;Publish Ahead of Print: 25. Weier AT, Pearce AJ, Kidgell DJ. Strength training reduces intracortical inhibition. Acta Physiologica. 2012;206:

8 Dialogue #2: Weakness and altered biomechanics: evidence for the positive effects of strengthening (Schmitt) 1. A substantial portion of patients after ACLR are discharged/cleared for return to highlevel activities with muscle strength deficits [23, 26, 28] a. 40% - 63% have quadriceps strength deficits at time of return to sport clearance 2. Quadriceps strength deficits persist for up to 2 years following ACLR [11,21] 3. Why is strength important after ACLR? a. Greater quadriceps strength early in rehabilitation is associated with better outcomes at discharge i. better function [25, 31] ii. better mechanics [7] b. Greater quadriceps and hip strength is a marker of successful outcome at RTS (better function and mechanics) [26, 27, 23, 4, 8, 15] c. Greater quadriceps strength is a marker of successful outcome after ACLR (better function and mechanics at 1 and 2 years post-aclr) [5,6] d. Quadriceps strength potential marker for long-term outcomes i. Risk for osteoarthritis is high in this population [16,18, 20] ii. Quadriceps strength related to joint space narrowing [30] and cartilage thickness [24] 4. Mechanisms underlying QF strength deficits [22] a. Muscle atrophy (decreased CSA) [29] b. Central activation deficits [13,14] 5. Rehabilitation strategies can increase demand on the quadriceps muscles [10, 3, 12, 19, 13] a. Open and closed kinetic chain 6. Strength as a key component of neuromuscular control [2,3] 7. Practice implications: Are we doing enough? a. Early strengthening, staged rehabilitation [9] i. Prehab? [1] b. Objective measures of strength c. Comprehensive intervention [17] References: 1. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med May;43(5): Garrison JC, Bothwell J, Cohen K, Conway J. Effects of hip strengthening on early outcomes following anterior cruciate ligament reconstruction. Int J Sports Phys Ther Apr;9(2): Gokeler A, Bisschop M, Benjaminse A, Myer GD, Eppinga P, Otten E.Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices. Knee Surg Sports Traumatol Arthrosc May;22(5): doi: /s x. Epub 2013 Jun 28.

9 4. Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC. Young Athletes With Quadriceps Femoris Strength Asymmetry at Return to Sport After Anterior Cruciate Ligament Reconstruction Demonstrate Asymmetric Single-Leg Drop-Landing Mechanics. Am J Sports Med Nov;43(11): Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC.Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sports Traumatol Arthrosc Sep 16. Epub ahead of print. 6. Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC.Young Athletes After Anterior Cruciate Ligament Reconstruction With Single-Leg Landing Asymmetries at the Time of Return to Sport Demonstrate Decreased Knee Function 2 Years Later. Am J Sports Med Sep;45(11): Kline PW, Burnham J, Yonz M, Johnson D, Ireland ML, Noehren B Hip external rotation strength predicts hop performance after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc Apr 4. Epub ahead of print 8. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am Oct 3;94(19): Kuenze C, Eltoukhy M, Kelly A, Kim CY. Impact of quadriceps strengthening on response to fatiguing exercise following ACLreconstruction. J Sci Med Sport Jan;20(1): Kuenze CM, Hertel J, Weltman A, Diduch D, Saliba SA, Hart JM. Persistent neuromuscular and corticomotor quadriceps asymmetry after anterior cruciate ligament reconstruction. J Athl Train Mar;50(3): Lepley LK, Palmieri-Smith R. Effect of eccentric strengthening after anterior cruciate ligament reconstruction on quadriceps strength. J Sport Rehabil May;22(2): Epub 2012 Dec 11. Review. 12. Lepley LK, Palmieri-Smith RM.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 Dec;45(12): Lepley LK, Palmieri-Smith RM. Pre-operative quadriceps activation is related to postoperative activation, not strength, in patients post-acl reconstruction. Knee Surg Sports Traumatol Arthrosc Jan;24(1): 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) Jan;17(1): Lidén M, Sernert N, Rostgård-Christensen L, Kartus C, Ejerhed L. Osteoarthritic changes after anterior cruciate ligament reconstruction using bone-patellar tendon-bone or hamstring tendon autografts: a retrospective, 7-year radiographic and clinical followup study. Arthroscopy Aug;24(8): Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L. Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc Apr;21(4): Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA. Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. Br J Sports Med May;43(5): Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior

10 cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8(6): Oiestad BE, Holm I, Aune AK, Gunderson R, Myklebust G, Engebretsen L, Fosdahl MA, Risberg MA. Knee function and prevalence of knee osteoarthritis after anterior cruciate ligamentreconstruction: a prospective study with 10 to 15 years of follow-up. Am J Sports Med Nov;38(11): Otzel DM, Chow JW, Tillman MD. Long-term deficits in quadriceps strength and activation following anterior cruciate ligament reconstruction. Phys Ther Sport Feb;16(1): Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med Jul;27(3): Palmieri-Smith RM, Lepley LK. Quadriceps Strength Asymmetry After Anterior Cruciate Ligament Reconstruction Alters Knee Joint Biomechanics and Functional Performance at Time of Return to Activity. Am J Sports Med Jul;43(7): Pamukoff DN, Montgomery MM, Moffit TJ, Vakula MN. Quadriceps Function and Knee Joint Ultrasonography following ACL Reconstruction. Med Sci Sports Exerc Oct Paterno MV, Bugada Mark, Quatman-Yates C, Schmitt LC. Effect of early quadriceps strength on function and patient confidence at the time of return to sport after ACL reconstruction. J Orthop Sports Phys Ther. 2017; 47(1):A162-A Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther Sep;42(9): Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE. Strength Asymmetry and Landing Mechanics at Return to Sport after Anterior Cruciate Ligament Reconstruction. Med Sci Sports Exerc Jul;47(7): Thomas AC, Villwock M, Wojtys EM, Palmieri-Smith RM. Lower extremity muscle strength after anterior cruciate ligament injury and reconstruction. J Athl Train Sep-Oct;48(5): Thomas AC, Wojtys EM, Brandon C, Palmieri-Smith RM. Muscle atrophy contributes to quadriceps weakness after anterior cruciate ligament reconstruction. J Sci Med Sport Jan;19(1): Zwolski C, Schmitt LC, Thomas S, Paterno MV. Early markers of outcome after ACL reconstruction. J Orthop Sports Phys Ther. 2017; 47(1):A162-A226.