Standing Flexion Deficits Predict Self-Reported Outcomes in Women After Ipsilateral Hamstring Anterior Cruciate Ligament Reconstruction


      To profile the standing flexion angle and its association with subjective outcomes in ipsilateral hamstring tendon autograft anterior cruciate ligament–reconstructed patients. A secondary aim was to describe prone position–measured hamstring strength as a predictor of flexion angle.


      Fifteen women (mean age, 20.47 ± 1.96 years; mean height, 1.69 ± 0.08 m; mean weight, 68.51 ± 12.64 kg; mean Tegner score, 6.80 ± 1.52), at a mean of 25.93 ± 11.25 months after surgery, were matched to 15 healthy participants by sex and approximate age, height, mass, and activity level (mean age, 20.93 ± 1.22 years; mean height, 1.65 ± 0.06 m; mean weight, 66.52 ± 10.69 kg; mean Tegner score, 6.13 ± 1.06). The independent variable was leg condition (involved, uninvolved, or matched). Dependent variables included goniometric flexion angle, Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores, and absolute isokinetic hamstring strength. We used 1-tailed paired and 2-sample t tests to analyze side and group differences, respectively. Corresponding effect sizes (d) were also quantified. Linear regression assessed relations between flexion angle and the KOOS, as well as strength and flexion angle. P < .05 denoted statistical significance.


      The involved leg showed a significantly lesser flexion angle (112.9° ± 8.1°) compared with the uninvolved leg (116.1° ± 8.4°, P = .024) and matched leg (117.1° ± 4.5°, P = .044), with corresponding weak side (d = 0.380) and strong group (d = 0.958) effect sizes. Significant associations existed between flexion angle and subjective outcomes (r2 = 60.3% and P = .001 for KOOS pain subscale, r2 = 37.8% and P = .015 for KOOS subscale for function in activities of daily living, and r2 = 39.2% and P = .012 for KOOS subscale for function in sports and recreation) for the involved leg. Hamstring strength was not a significant predictor of flexion angle for all legs (P > .05).


      Our results support the hypotheses that standing flexion angle insufficiencies exist for the involved leg, superior subjective outcomes are associated with greater flexion capacity, and hamstring strength at deep knee angles does not predict the standing flexion angle.

      Level of Evidence

      Level IV, therapeutic study, case series.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Harner C.D.
        • Irrgang J.J.
        • Paul J.
        • Deanwater S.
        • Fu F.H.
        Loss of motion after anterior cruciate ligament reconstruction.
        Am J Sports Med. 1992; 20: 499-506
        • Adachi N.
        • Ochi M.
        • Uchio Y.
        • Sakai Y.
        • Kuriwaka M.
        • Fujihara A.
        Harvesting hamstring tendons for ACL reconstruction influences postoperative hamstring muscle performance.
        Arch Orthop Trauma Surg. 2003; 123: 460-465
        • Arden C.L.
        • Webster K.E.
        • Taylor N.F.
        • Feller J.A.
        Hamstring strength recovery after hamstring tendon harvest for anterior cruciate ligament reconstruction: A comparison between graft types.
        Arthroscopy. 2010; 26: 462-469
        • Nakamura N.
        • Horibe S.
        • Sasaki S.
        • et al.
        Evaluation of active knee flexion and hamstring strength after anterior cruciate ligament reconstruction using hamstring tendons.
        Arthroscopy. 2002; 18: 598-602
        • Arden C.L.
        • Webster K.E.
        Knee flexor recovery following hamstring tendon harvest for anterior cruciate ligament reconstruction: A systematic review.
        Orthop Rev (Pavia). 2009; 1: e12
        • Carofino B.
        • Fulkerson J.
        Medial hamstring tendon regeneration following tendon harvest for anterior cruciate ligament reconstruction: Fact, myth and clinical implication.
        Arthroscopy. 2005; 21: 1257-1264
        • Duquin T.R.
        • Wind W.M.
        • Fineberg M.S.
        • Smolinski R.J.
        • Buyea C.M.
        Current trends in anterior cruciate ligament reconstruction.
        J Knee Surg. 2009; 22: 7-12
        • McRae S.M.
        • Chahal J.
        • Leiter J.R.
        • Marx R.G.
        • MacDonald P.B.
        Survey study of members of the Canadian orthopaedic association on the natural history and treatment of anterior cruciate ligament injury.
        Clin J Sports Med. 2011; 21: 249-258
        • Vairo G.L.
        • Myers J.B.
        • Sell T.C.
        • Fu F.H.
        • Harner C.D.
        • Lephart S.M.
        Neuromuscular and biomechanical landing performance subsequent to ipsilateral semitendinosus and gracilis autograft anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2008; 16: 2-14
        • Shelbourne K.D.
        • Gray T.
        Minimum 10-year results after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2009; 37: 471-480
      1. 2000 International Knee Documentation Committee knee forms. Available from: Accessed August 15, 2012.

      2. Centers for Disease Control and Prevention. Physical Activity Guidelines for Americans—Physical Activity for Adults. Available from: Updated December 1, 2011. Accessed August 30, 2012.

        • Folsom A.R.
        • Jacobs Jr., D.R.
        • Caspersen C.J.
        • Gomez-Marin O.
        • Knudsen J.
        Test-retest reliability of the Minnesota leisure time physical activity questionnaire.
        J Chronic Dis. 1986; 39: 505-511
        • Richardson M.T.
        • Leon A.S.
        • Jacbos D.R.
        • Ainsworth B.E.
        • Serfass R.
        Comprehensive evaluation of the Minnesota leisure time physical activity questionnaire.
        J Clin Epidemiol. 1994; 47: 271-281
        • Briggs K.K.
        • Lysholm J.
        • Tegner Y.
        • Rodkey W.G.
        • Kocher M.S.
        • Steadman J.R.
        The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later.
        Am J Sports Med. 2009; 37: 891-897
        • Briggs K.K.
        • Steadman J.R.
        • Hay C.L.
        • Hines S.L.
        Lysholm score and Tegner activity level in individuals with normal knees.
        Am J Sports Med. 2009; 37: 898-901
        • Salvanti M.
        • Akhbari B.
        • Mohammadi F.
        • Mazaheri M.
        • Khorrami M.
        Knee injury and osteoarthritis score (KOOS): Reliability and validity in competitive athletes after anterior cruciate ligament reconstruction.
        Osteoarthritis Cartilage. 2011; 19: 406-410
        • Roos E.M.
        • Lohmander L.S.
        The Knee injury and Osteoarthritis Outcome Score (KOOS): From joint injury to osteoarthritis.
        Health Qual Life Out. 2003; 1: 64
        • Pincivero D.M.
        • Lephart S.M.
        • Karunakara R.A.
        Reliability and precision of isokinetic strength and muscular endurance for the quadriceps and hamstrings.
        Int J Sports Med. 1997; 18: 113-117
        • Davies G.J.
        • Ellenbecker T.S.
        Eccentric isokinetics.
        Orthop Phys Ther Clin North Am. 1992; 12: 297-336
        • Woods S.
        • Bridge T.
        • Nelson D.
        • Risse K.
        • Pincivero D.M.
        The effect of rest interval length on ratings of perceived exertion during dynamic knee extension exercise.
        J Strength Cond Res. 2004; 18: 540-545
        • Pua Y.H.
        • Bryant A.L.
        • Steele J.R.
        • Newton R.U.
        • Wrigley T.V.
        Isokinetic dynamometry in anterior cruciate ligament injury and reconstruction.
        Ann Acad Med Singapore. 2008; 37: 330-340
        • Montgomery L.C.
        • Douglass L.W.
        • Deuster P.A.
        Reliability of an isokinetic test of muscle strength and endurance.
        J Orthop Sports Phys Ther. 1989; 10: 315-322
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        Ed 2. Lawrence Erlbaum Associates, Hillsdale, NJ1988
        • Roach K.E.
        • Miles T.P.
        Normal hip and knee active range of motion: The relationship to age.
        Phys Ther. 1991; 71: 656-665
        • Biggs A.
        • Jenkins W.L.
        • Urch S.E.
        • Shelbourne K.D.
        Rehabilitation for patients following ACL reconstruction: A knee symmetry model.
        N Am J Sports Phys Ther. 2009; 4: 2-12
        • Hiemstra L.A.
        • Webber S.
        • MacDonald P.B.
        • Kriellaars D.J.
        Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft.
        Clin Biomech. 2007; 22: 543-550
        • Roberts D.
        • Friden T.
        • Stomberg A.
        • Lindstrand A.
        • Moritz U.
        Bilateral proprioceptive deficits in patients with unilateral anterior cruciate ligament reconstruction: A comparison between patients and healthy individuals.
        J Orthop Res. 2000; 18: 565-571
        • Irrgang J.J.
        • Harner C.D.
        Loss of motion following knee ligament reconstruction.
        Sports Med. 1995; 19: 150-159
        • Shelbourne K.D.
        • Biggs A.
        • Gray T.
        Deconditioned knee: The effectiveness of a rehabilitation program that restores normal knee motion to improve symptoms and function.
        N Am J Sports Phys Ther. 2007; 2: 81-89
        • Bohannon R.W.
        Relationship between active range of motion deficits and muscle strength and tone at the elbow in patients with hemiparesis.
        Clin Rehabil. 1991; 5: 219-224
        • Shelbourne K.D.
        • Urch S.E.
        • Gray T.
        • Freeman H.
        Loss of normal knee motion after anterior cruciate ligament reconstruction is associated with radiographic arthritic changes after surgery.
        Am J Sports Med. 2012; 40: 108-113
        • McGinty G.
        • Irrgang J.J.
        • Pezzullo D.
        Biomechanical considerations for rehabilitation of the knee.
        Clin Biomech. 2000; 15: 160-166