PEKKA KANNUS, MD* Downloaded from at on April 8, For personal use only. No other uses without permission.

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1 /88/ $02.00/0 THE OURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyight by The Othopaedic and Spots Physical Theapy Sections of the Ameican Physical Theapy Association Peak Toque and Total Wok Relationship in the Thigh Muscles afte Anteio Cuciate Ligament Injuy PEKKA KANNUS, MD* ounal of Othopaedic & Spots Physical Theapy The pupose of the pesent study was to 1) assess the elationship between the isometic and isokinetic peak toques (speed of movement 0, 60, 180 /sec) and the total wok output of multiple contactions (1 80 /sec) of the quadiceps and hamstings in 36 patients having a chonic anteio cuciate ligament (ACL) insufficient knee joint, and 2) detemine the possible association of these muscle function paametes with the subjective and functional outcome of the ACL insufficient knees. At evey test speed the Peason poduct moment () and the Speaman ank (,) coelation coefficients between the peak toque and the total wok wee highly significant fo the quadiceps and hamstings in the uninjued ( = , s = ) as well as in the anteioly unstable ( = , s = ) knees. All coelation coefficients wee highe at the highest speed (180 /sec) of the isokinetic test ( = , s = ) than at the othe speeds (0 and 60 /sec) ( = , s = ) obviously since the total wok was egisteed at that speed. Both the peak toque and total wok paametes of quadiceps as well as hamstings coelated significantly with the subjective and functional outcome of the ACL insufficient knees ( = , s = ): the bette the muscula function the bette the outcome. In conclusion, in anteioly unstable knees the total wok analysis offes little additional infomation to that attained by the peak toque measuements. The development of isokinetic stength testing peak toq~e.~.'~ Also, afte anteio cuciate ligadevices to commecial vesions has inceased the ment econstuctions, the same kind of esults outine isokinetic testing of knee patients. The can be ~een?.~.'~ Recently, Moisseyl1 found most commonly used paamete has been peak that quadiceps and hamstings peak toque and toque coesponding to the single highest toque wok of a single contaction at the high speed of output of the joint poduced by muscula contac- movement (120, 180, 240 /sec) ae highly coetion as the limb moves though the ange of lated fo both the injued and uninjued extemity motjon.2, '3 afte athoscopic patial meniscectomy. He, how- Howeve, today the isokinetic dynamometes eve, ecommended that analyses of othe knee ae almost without exception compute linked, pathologies such as patellofemoal athalgia, ligand theefoe many othe Paametes (e.g., an- amentous instability, etc. should be pefomed to gula specific toques, toque acceleation enegy, detemine if the peak toquelwok coelation is aveage Powe, and wok) ae also easily avail- dependent on the natue of the injuy and if wok able. Especially the elationship between peak is pedictable fom peak toque at othe speeds toque and (total) wok has been a taget of of movement as well. gowing intee~t.~*~*~m'~~ " The aim of this study was to analyze the ela- Wok is defined in isokinetics as the aea unde tionship between peak toque and the total wok the toque c ~ve.~~~~"-'~ In healthy pesons a high output of multiple, (speed of movement (0, 60, coelation has been noted between wok and 180 /sec) contactions of the quadiceps and hamstings in patients having an anteioly unstable knee, joint because of the total loss of the Tampee Reseach Station of Spots Medicine and Depatment of Clinical Sciences, Univesity of Tampee, Tampee, Finland. anteio cuciate ligament (ACL). In addition, the 97

2 ounal of Othopaedic & Spots Physical Theapy 98 KANNUS OSPT Vol. 10, No. 3 association of these muscle function paametes with the subjective and functional outcome of the ACL insufficient knees was detemined. PATIENTS AND METHODS Subjects wee 36 patients who had a chonic (mean time y fom the knee injuy) anteio instability of one knee veified in most of the cases by examination unde anesthesia and/ o athoscopy and/o athotomy. Thei ages anged fom 16 to 59 y with a mean age of 34. The ight knee was involved in 15 and the left in 21 cases. None of the subjects had injuy of the opposite knee. Pio to testing each subject was given a 5 minute wam-up peiod by aeobic egomete cycling. The patient was then fixed to the testing appaatus (Cybex I$ isokinetic dynamomete with micocompute; Cybex, Division of Lumex, Inc., Ronkonkoma, NY 11779) with staps secuing the chest, pelvis, thigh, and malleoli. Befoe testing, the subject was instucted to pefom a sufficient amount of submaximal and theeafte two maximal epetitions of knee extension and flexion at both isokinetic test velocities (60 and 180 /sec) in ode to familiaize with the system. The isokinetic quadiceps and hamstings peak toques wee then measued fist at a lowe speed (60 /sec) and afte a 1 minute est at a highe speed (180 /sec). Six maximal voluntay muscula toque contactions wee equied and the best peak toque value of the knee extension and flexion was e~oded.~ The total wok was egisteed as the wok poduced by the six epetitions at the speed of 180 /sec. One minute afte the isokinetic tests, the maximal isometic extension and flexion stength was measued at a knee flexion angle of 60' fom full extension (full extension = 0'). Befoe isometic testing the subject pefomed one maximal taining effot. In evey othe subject of the goup, the unaffected knee was tested fist and, in evey othe, vice vesa to eliminate any leaning effect. The detailed desciption of the test potocol has been published pevi~usly.~ Fo the hamstings and quadiceps of the ACL insufficient knees, the mean elative extension and flexion peak toque and total wok deficits wee calculated coesponding to the aveage value of the pecent deficits measued isokinetically at 60 and 180 /sec and isometically at 60' of flexion. The subjective and functional evaluation of the patients was pefomed using Lysholm's knee scoing scale.8 It evaluated the subjective and functional status of the knees by ecoding and scoing the following vaiables: limp, suppot, stai climbing, squatting, instability, pain and swelling duing walking, unning and jumping, and thigh atophy. The maximum 100 points was given to a fully nomal knee joint. All the data wee stoed at DEC-2060 compute of Tampee Univesity using in analysis the pogam libaies of BMDP-6D, -lr and -3s.' Fo quadiceps and hamstings of both extemities the Peason poduct moment coelation coefficient () and the Speaman ank coelation coefficient (,) between the peak toque and the total wok was calculated at evey test speed. The esidual eo of each coelation was analyzed by a linea egession technique. The same coelation coefficients wee used to detemine the association between the elative value of peak toque and total wok and the Lysholm scoe in the ACL insufficient knees. The given significance levels efe to two-tailed tests, and only the level less than 0.1% (p < 0.001) was consideed as significant. RESULTS At evey test speed (0, 60, 180 /sec) the coelation coefficients between the peak toque and the total wok wee significant in the quadiceps and hamstings in the uninjued ( = ,, = ) (Tables 1 and 2) as well as in the anteio cuciate ligament insufficient ( = ,, = ) (Tables 3 and 4) knees. The egession analysis evealed that in each coelation the standad eo of the egession equation was small, and that in each coelation the esiduals wee distibuted nonsystematically, i.e., the seial coelation of esiduals was small and not significant (Tables 1-4). In both knees the coelation coefficents of the quadiceps ( = ,, = ) wee slightly, but not significantly highe than those of the hamstings ( = ,, = ). In addition, in both knees in both muscle goups the coelation coefficients wee slightly highe at the highest speed of the isokinetic test (1 80 /sec) ( = ,, = ) than at the othe speeds (0 and 60 /sec) ( = ,, = ). Also in both muscle goups at the highest test speed (1 80 /sec) the coelation coefficients

3 OSPTSeptembe 1988 PEAK TORQUE AND TOTAL WORK RELATIONSHIP 99 ounal of Othopaedic & Spots Physical Theapy TABLE 1 Quadiceps peak toque and total wok of uninjued knee. Mean + SD and median (ange). speed Peak Toque Total Wok OO/sec (isometic) ' < (90-390) 51 0 ( ) 0.81 < /sec (isokinetic) t < (82-279) 51 0 ( ) 0.85 < /sec (isokinetic) * $ < ( ) 51 0 ( ) 0.88 <0.001, Newton mete;, oule;, Peason poduct moment coelation coefficient;, Speaman ank coelation coefficient; RE, egession equation; SE, standad eo of the egession equation; SCR, seial coelation of esiduals. * RE, y = 2.09~ ; SE, 111 ; SCR, t RE, y = 3.54~ ; SE, 89 ; SCR, $ RE, y = 5.98~ ; SE, 72 ; SCR, TABLE 2 Hamstings peak toque and total wok of uninjued knee. Mean + SD and median (ange). speed Peak Toque Total Wok. P * P OO/sec (isometic) ' < ( ) 430 (86-758) 0.70 < /sec (isokinetic) 107 -C C t < ( ) 430 (86-758) 0.79 < /sec (isokinetic) $ < ( ) 430 (86-758) 0.90 <0.001, Newton mete;, oule;, Peason poduct moment coelation coefficient;, Speaman ank coelation coefficient; RE, egession equation; SE, standad eo of the egession equation; SCR, seial coelation of esiduals. ' RE, y = 3.98~ ; SE, 135 ; SCR, t RE, y = 4.26~ ; SE, 113 ; SCR, $ RE, y = 6.18x ; SE, 81 ; SCR, TABLE 3 Quadiceps peak toque and total wok of the anteio cuciate ligament insufficient knee. Mean + SD and median (ange). speed Peak Toque Total Wok * P OO/sec (isometic) * < ( ) 391 (56-868) 0.85 < /sec (isokinetic) t < (42-263) 391 (56-868) 0.79 < /sec (isokinetic) $ < ( ) 391 (56-868) 0.86 <0.001, Newton mete;, oule;, Peason poduct moment coelation coefficient;, Speaman ank coelation coefficient; RE, egession equation; SE, standad eo of the egession equation; SCR, seial coelation of esiduals. ' RE, y = 1.95~ ; SE, 100 ; SCR, t RE, y = 3.15~ ; SE, 112 ; SCR, $ RE, y = 5.00~ ; SE, 95 ; SCR, wee slightly bette in the healthy than in the lated equally and significantly with the Lysholm injued side. scoes: the neae the muscle function of the ACL The mean elative peak toque deficit of ham- insufficient knee was that of the uninjued side, stings in the ACL insufficient knee was 18 & the bette the scoes (Table 5). 140h, and of quadiceps 24 a 15%. Coesponding to total wok the espective values wee 25 & 20% and 31 & 1g0/0. The Lysholm scoes ave- D~SCUSS~ON aged 60 & 21 points. In both muscle goups the The esults of this study ae in ageement with mean elative peak toque and total wok coe- pevious studies concening the close elationship

4 ounal of Othopaedic & Spots Physical Theapy 100 KANNUS OSPT Vol. 10, No. 3 TABLE 4 Hamstings peak toque and total wok of the anteio cuciate ligament insufficient knee. Mean * SD and median (ange). speed Peak Toque Total Wok. P OO/sec (isometic) 88 & & ' < ( ) 351 (34-691) 0.82 < /sec (isokinetic) 96 f t < ( ) 351 (34-691) 0.81 < /sec (isokinetic) 65 * f $ < ( ) 351 (34-691) 0.85 <0.001, Newton mete;, oule;, Peason poduct moment coelation coefficient;,, Speaman ank coelation coefficient; RE, egession equation; SE, standad eo of the egession equation; SCR, seial coelation of esiduals. ' RE, y = 3.96~ ; SE, 106 ; SCR, t RE, y = 4.08~ ; SE, 108 ; SCR, $RE, y = 5.28~ ; SE, 99 ; SCR, TABLE 5 Coelation between the muscle function paametes (the mean elative peak toque and total wok of hamstings and quadiceps) and the subjective and functional outcome (Lysholm scoe) of the ACL insufficient knees. Muscle Function Paamete Lysholm Scoe' P Peak toque Hamstings = 0.76 <0.001, = 0.78 <0.001 Quadiceps = 0.84 ~0.001, = 0.85 <0.001 Total wok Hamstings = 0.75 <0.001, = 0.76 <0.001 Quadiceps = 0.82 <0.001, = 0.84 <o.ool Accoding to this study, total wok could be acceptably pedicted fom peak toque in the anteioly unstable knee. Howeve, peak toque and wok ae just two measues of isokinetic muscula output available to the clinician." Futhe eseach is needed to ascetain the value of the othe paametes (angula specific toques, toque acceleation enegy, aveage powe, etc.) of a compute linked isokinetic dynamomete in assessment of isokinetic muscula pefomance in diffeent states of knee pathology. The pesent study showed that both of the measued muscle function paametes (peak toque and total wok) wee in significant coe- * = peason poduct moment coelation coefficient; s = lation with the subjective and functional outcome Speaman ank.coelation coefficient. (Lysholm scoes) of the ACL insufficient knees. ~lso, in this espect, the peak toque was equal between the peak toque and ~ok.~,~.'~'~," This study showed that the peak toque is a good indicato of the quadicep's and hamsting's ability to emit foce thoughout the ange of motion, not only in the healthy knee but also in the ACL insufficient knee. Fo both muscle goups of each leg the coelations between the peak toque and the total wok wee high and significant. This finding is vey impotant when assessing the value of simple "field tests," such as maximal isometic knee extension at 60' of flexion, fo lage population studies. At both knees in quadiceps and hamstings the coelation coefficients wee highest at the highest speed of the isokinetic test (180 /sec). This seems quite natual, since the total wok was egisteed as the wok poduced by the six epetitions of this speed. Obviously, if the peak toque and wok of a single contaction had been measued, as Moissey ecently epoted in his study of meniscectomized patients," the coelation coefficients might have been even highe. to the total wok. The neae the muscula pefomance of the ACL insufficient knee was that of the uninjued side, the bette was the outcome and vice vesa. Howeve, one should keep in mind that this coss-sectional study did not answe the question if good muscle function of these ACL insufficient knees was a cause-o only a esult-of good subjective and functional outcome, o if poo mus- cle function was a cause-o only a consequence-of poo ecovey. Tegne et ai.l4 have shown that by intensive stength taining of the injued extemity the majoity of the study patients with old toublesome cuciate ligament lesions had significant subjective and functional impovement thus avoiding the planned ligament econstuction. In othe wods, thei study showed that poo muscle function also can be a causal facto of poo ecovey, since by coecting the muscula pefomance the outcome impoved significantly. This finding may be en-

5 OSPTSeptembe 1988 PEAK TORQUE AND TOTAL WORK RELATIONSHIP 101 ounal of Othopaedic & Spots Physical Theapy couaging to a pacticing physiotheapist o physician when motivating a ehabilitation pogam fo a patient with a knee injuy. CONCLUSION The esults of this study demonstate that in healthy as well as anteioly unstable knees the total wok of quadiceps and hamsting muscles can be acceptably pedicted fom moe simple measuements, the isometic and isokinetic peak toque analyses, which is impotant when assessing the value of these simple field tests fo lage population studies. The study also demonstated that peak toque as well as total wok of the quadiceps and hamsting muscles shows a significant coelation with the subjective and functional esultant state of the anteio cuciate ligament insufficient knee, suggesting that undistubed muscle function may be cucial fo optimal ecovey afte a knee ligament injuy. REFERENCES 1. BMDP Statistical Softwae. Dixon W, ed. Bekeley: Univesity of Califonia Pess, Bunie, Bodie DA: lsokinetic measuement in peadolescent males. Int Spots Med 7: , Davies G. Ross DE. Gould A, Rowinski M: Computeized Cybex testing of ACL econstuction assessing quadiceps peak toque, TAE, total wok and aveage powe. Med Sci Spots (Abst) 16:204, Gould A, Davies G, Ross DE, Rowinski M: Computeized Cybex testing of ACL econstuction assessing hamstings peak toque, TAE, total wok and aveage powe. Med Sci Spots (Abst) 16:204, Hislop H, Penine : The isokinetic concept of execise. Phys The 47: Kannus P, Winen M, Latvala K: Knee stength evaluation. A standadized test potocol and scoing scale fo isokinetic and isometic stength measuements of the knee joint fo evaluation of long-tem healing esults of vaious knee poblems and thei teatment pocedues. Scand Spots Sci 9:9-13, Knapik, ones BH, Bauman C, Hams. Wight : Relationship between peak toque, aveage and total wok in an isokinetic contaction. Med Sci Spots 14:178, Lysholm, Gillquist : Evaluation of knee ligament sugey esults with special emphasis on use of a scoing scale. Am Spots Med 10: , Moffoid M. Whipple R, Mofkosh, Lowman E, Thistle A: A study of isokinetic execise. Phys The 49: , Moffoid M, Kusiak ET: The powe stuggle: definition and evaluation of powe of muscula pefomance. Phys The 55: , Moissey MC: The elationship between peak toque and wok of the quadiceps and hamstings afte meniscectomy. Othop Spots Phys The 8: Roth H, Kennedy C, Lockstadt H, McCallum CL, Cunning LA: Polypopylene baid augmented and nonaugmented intaaticula anteio cuciate ligament econstuction. Am Spots Med 13: , Rothstein M, Delitto A, Sinacoe DR, Rose S: Electomyogaphic, peak toque, and powe elationships duing isokinetic movement. bhys he 63: , Tegne Y, Lysholm, Lysholm M, Gillquist : Stengthening execises fo old cuciate ligament teas. Acta Othop Scand 57: , Zains B, Rowe C: Combined anteio cuciate ligament econstuction using semitendinosus tendon and iliotibial tact. Bone oint Sug (Am) 68: