Limb dominance influences landing mechanics and neuromuscular control during drop vertical jump in patients with ACL reconstruction

Abstract

Objectives
The purpose of this study was to compare the interlimb biomechanical differences in patients who had undergone anterior cruciate ligament reconstruction (ACLR) in either dominant (ACLR-D) or nondominant (ACLR-ND) limbs and healthy controls (CON) during drop vertical jump (DVJ) task. To investigate whether the dominant or nondominant limb influences the risk of re-injury in ACLR patients.

Methods
Thirty-three ACLR patients were divided into ACLR-D and ACLR-ND groups according to whether the surgical limb was dominant or nondominant. Seventeen healthy individuals were selected as the CON group. Three-dimensional kinematic data, ground reaction force (GRF) data, and surface electromyographic (EMG) data from the bilateral lower limbs of all participants were collected during the DVJ task. Two-way repeated-measures ANOVAs (limb × group) were performed on the variables of interest to examine the main effects of limb (dominant vs. nondominant) and group (ACLR-D, ACLR-ND, and CON), as well as the interaction between limb and group.

Results
The nonsurgical limbs of ACLR group had significantly greater knee valgus angles, knee extension and valgus moments, peak posterior GRF (PPGRF), and peak vertical GRF (PVGRF) compared to the surgical limbs. The nonsurgical limbs of ACLR-ND patients demonstrated significantly greater knee extension and valgus moments, greater PPGRF and PVGRF, and reduced muscle activity in the vastus medialis and vastus lateralis compared to the CON group. The ACLR patients had reduced muscle activity in the quadriceps of the surgical limb and the hamstrings of the bilateral limbs compared to controls.

Conclusion
The nonsurgical limbs of ACLR patients may suffer an increased risk of ACL injury due to altered landing mechanics and neuromuscular control strategies compared to the surgical limbs. Additionally, limb dominance influences movement patterns and neuromuscular control during DVJ task, the nonsurgical limbs of the ACLR-ND might be at higher risk of ACL injury compared to the ACLR-D group.

Full text

TYPE Original Research
PUBLISHED 21 October 2024
DOI 10.3389/fphys.2024.1488001
OPEN ACCESS
EDITED BY
Pui Wah Kong,
Nanyang Technological University, Singapore
REVIEWED BY
Nijia Hu,
University of Jyväskylä, Finland
Cheng Liang,
Sichuan Sports College, China
*CORRESPONDENCE
Chen Yang,
chen_yang@nsi.edu.cn
Zhipeng Zhou,
zhouzhipeng@sdpei.edu.cn
RECEIVED 29 August 2024
ACCEPTED 04 October 2024
PUBLISHED 21 October 2024
CITATION
Xue B, Yang X, Wang X, Yang C and Zhou Z
(2024) Limb dominance inuences landing
mechanics and neuromuscular control during
drop vertical jump in patients with ACL
reconstruction.
Front. Physiol. 15:1488001.
doi: 10.3389/fphys.2024.1488001
COPYRIGHT
© 2024 Xue, Yang, Wang, Yang and Zhou. This
is an open-access article distributed under
the terms of the Creative Commons
Attribution License (CC BY). The use,
distribution or reproduction in other forums is
permitted, provided the original author(s) and
the copyright owner(s) are credited and that
the original publication in this journal is cited,
in accordance with accepted academic
practice. No use, distribution or reproduction
is permitted which does not comply with
these terms.
Limb dominance inuences
landing mechanics and
neuromuscular control during
drop vertical jump in patients
with ACL reconstruction
Boshi Xue1, Xiaowei Yang1,2, Xia Wang1, Chen Yang3*and
Zhipeng Zhou1*
1College of Sports and Health, Shandong Sport University, Jinan, China, 2Faculty of Sports Science,
Ningbo University, Ningbo, China, 3College of Sports and Health, Nanjing Sport Institute, Nanjing,
China
Objectives: The purpose of this study was to compare the interlimb
biomechanical dierences in patients who had undergone anterior cruciate
ligament reconstruction (ACLR) in either dominant (ACLR-D) or nondominant
(ACLR-ND) limbs and healthy controls (CON) during drop vertical jump (DVJ)
task. To investigate whether the dominant or nondominant limb inuences the
risk of re-injury in ACLR patients.
Methods: Thirty-three ACLR patients were divided into ACLR-D and ACLR-ND
groups according to whether the surgical limb was dominant or nondominant.
Seventeen healthy individuals were selected as the CON group. Three-
dimensional kinematic data, ground reaction force (GRF) data, and surface
electromyographic (EMG) data from the bilateral lower limbs of all participants
were collected during the DVJ task. Two-way repeated-measures ANOVAs (limb
× group) were performed on the variables of interest to examine the main eects
of limb (dominant vs. nondominant) and group (ACLR-D, ACLR-ND, and CON),
as well as the interaction between limb and group.
Results: The nonsurgical limbs of ACLR group had signicantly greater knee
valgus angles, knee extension and valgus moments, peak posterior GRF (PPGRF),
and peak vertical GRF (PVGRF) compared to the surgical limbs. The nonsurgical
limbs of ACLR-ND patients demonstrated signicantly greater knee extension
and valgus moments, greater PPGRF and PVGRF, and reduced muscle activity in
the vastus medialis and vastus lateralis compared to the CON group. The ACLR
patients had reduced muscle activity in the quadriceps of the surgical limb and
the hamstrings of the bilateral limbs compared to controls.
Conclusion: The nonsurgical limbs of ACLR patients may suer an
increased risk of ACL injury due to altered landing mechanics and
neuromuscular control strategies compared to the surgical limbs.
Additionally, limb dominance inuences movement patterns and
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Xue etal. 10.3389/fphys.2024.1488001
neuromuscular control during DVJ task, the nonsurgical limbs of the ACLR-ND
might be at higher risk of ACL injury compared to the ACLR-D group.
KEYWORDS
ACLR, landing strategy, landing mechanics, muscle activation, return to sport
1 Introduction
Anterior cruciate ligament (ACL) injuries are among the most
prevalent severe sports injuries, accounting for approximately
50% of all knee injuries (Mosesetal., 2012;Kaedingetal.,
2017). Following ACL injuries, patients experience abnormal
neuromuscular control, decreased knee stability, and increased risk
of knee osteoarthritis (Howellsetal., 2011;Gersingetal., 2021).
ACL reconstruction (ACLR) is a common surgical treatment
following ACL injuries, contributing to restoring knee function
and safely returning to play. However, a quarter of young athletic
patients suered an ACL re-injury (Wigginsetal., 2016), suggesting
signicantly higher injury rates compared to primary ACL injuries.
e incidence rates of the surgical limb and nonsurgical limb
were reported as 7%–12% and 18%–28%, respectively (Webster
and Feller, 2016;Lindangeretal., 2019). erefore, it is critical to
monitor the rehabilitation progress on both surgical and nonsurgical
limbs following ACLR.
Bilateral asymmetries in knee mechanics during landing
were commonly observed following ACLR (Johnstonetal.,
2018;Kingetal., 2021;Kotsifakietal., 2022b;Kotsifakietal.,
2022a), which has been considered as ACL reinjury risk factors
(Johnstonetal., 2018;Kingetal., 2021). e surgical limbs typically
exhibit smaller knee exion angles, knee extension moments, and
ground reaction force (GRF) during landing (Johnstonetal., 2018;
Kotsifakietal., 2022a), whereas greater knee joint contact forces
and ACL forces are present in the nonsurgical limbs (Wrenetal.,
2018;Rushetal., 2024). In fact, the limb dominance may be
associated with bilateral asymmetry in health populations during
jump task (Edwardsetal., 2012). Abnormal landing kinematics and
kinetics for dominant and nondominant limbs, including greater
valgus angles and peak GRF for nondominant limbs during jumps
(Wollschläger-Tigges and Simpson, 2016;Nakahiraetal., 2022), as
well as higher knee extension moments and quadriceps activation
for dominant limbs (Yılmaz and Kabadayı, 2022), may contribute
to increased risk of ACL injuries. erefore, whether the limb
dominance contributes to the bilateral asymmetry in ACLR patients
need to be investigated.
In fact, recent work reported the bilateral biomechanical
characteristics in relation to the limb dominance following
ACLR; however, the results for dominant and nondominant
are inconclusive (Dos’Santosetal., 2019;Malafronteetal., 2021;
Farmeretal., 2022;Gotoetal., 2022). A recent study showed
that for the surgical limb, patients underwent ACLR on the
nondominant limb had greater knee loading (peak knee extension
moments, peak patellofemoral joint stresses) during walking
compared to patients underwent ACLR on the dominant limb
(Gotoetal., 2022). Conversely, Malafronteetal. (2021) reported
that patients with ACLR on the dominant limb demonstrated
greater knee joint loading in surgical limb compared to
nondominant ACLR during jump-landing task. Meanwhile, for
nonsurgical limbs, the results between dominant and nondominant
limbs seem to be contradictory. Gotoetal. (2022) found that
dominant ACLR patients carried 49% more knee load in walking
than nondominant ACLR patients. However, Malafronte etal.
demonstrated that dominant ACLR patients carried 76% less
knee load than nondominant ACLR patients performing jump-
landing task (Malafronteetal., 2021). e above results suggest
that there may be biomechanical dierences between dominant
and nondominant limbs in patients with ACLR, but the ndings
regarding the risk of secondary ACL injury or gra rupture in the
surgical and nonsurgical limbs are inconsistent across studies.
e purpose of this study was to compare the biomechanical
characteristics of bilateral limbs in patients who had undergone
ACLR in either dominant (ACLR-D) or nondominant (ACLR-ND)
limbs and healthy controls (CON) during drop vertical jump (DVJ)
task. We hypothesized that (1) the nonsurgical limbs would exhibit
smaller knee exion angles, greater GRFs, greater knee extension
and valgus moments, and greater quadriceps and hamstring muscle
activation compared to the surgical limbs, regardless of ACLR-
D or ACLR-ND group, and (2) the nonsurgical limbs in the
ACLR-ND group would exhibit smaller knee exion angles, greater
knee extension and valgus moments, greater GRFs, and greater
quadriceps and hamstring muscle activation compared to the
nonsurgical limbs in the ACLR-D group.
2 Material and methods
2.1 Participants
Based on an estimated eect size of 0.78 for dierences in
knee extension moments between limbs of the ACL-D and ACL-
ND (Gotoetal., 2022), a sample size of 12 was required to achieve
a power of 80% at a type I error rate of 0.05. A total of 50 male
participants were recruited to complete this study, including three
groups: (1) patients who underwent ACLR on their dominant limb
(ACLR-D group, n = 17); (2) patients who underwent ACLR on
their nondominant limb (ACLR-ND group, n = 16); (3) Healthy
individuals matched for age, height, weight, and physical activity
level to the ACLR patients, were selected as the control group (CON
group, n = 17).
e patients with ACLR were recruited from Qilu Hospital
of Shandong University, and the participants of CON group
were recruited from Shandong Sport University. e inclusion
criteria for this study were as follows: (1) aged 18–40 years;
(2) Unilateral hamstring tendon reconstruction without combined
meniscal medial collateral ligament injury; (3) hospital-assessed
to meet criteria for return to sport; (4) 10–14 months aer
ACLR; (5) Willingness to return to sports (RTS) aer ACLR;
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TABLE 1 Participant information (mean ± SD).
ACLR-D ACLR-ND CON One-way ANOVA/T-test
(n = 17) (n = 16) (n = 17) F/t value P-Value
Age (years) 24.1 ± 4.3 23.9 ± 1.7 23.4 ± 1.6 0.242a0.786
Height (cm) 176.4 ± 5.1 175.9 ± 5.7 178.1 ± 6.8 0.601a0.553
Weight (kg) 76.6 ± 9.4 72.7 ± 11.3 73.6 ± 15.4 0.475a0.625
Dominant limb, right/le (n) 11/6 11/5 16/1 NA NA
Postoperative duration (months) 12.1 ± 1.6 11.8 ± 1.6 NA 0.442b0.662
IKDC (score) 87.2 ± 9.4 86.6 ± 6.4 NA 0.447b0.658
Tegner Activity Scale (score) 6.9 ± 1.4 6.6 ± 1.4 6.8 ± 1.2 0.356a0.703
IKDC, International Knee Documentation Committee; ACLR-D, anterior cruciate ligament reconstruction on dominant limb; ACLR-ND, anterior cruciate ligament reconstruction on
nondominant limb; CON, control; NA, not available.
aF-value for one-way ANOVA.
bt-value for independent samples T-test.
(6) both pre-injury ACLR patients and healthy athletes regularly
participated in at least one physical activity daily; (7) Tegner Activity
Scale ≥5. e exclusion criteria were as follows: (1) knee-related
injury within 3 months; (2) previous other knee-related surgeries;
(3) severe cardiovascular and neurological disease history; (4)
visual impairment and intolerable associated organ disease. e
study was approved by the Ethics Committee of Sports Science
of Shandong Sports University (approval number: 2023004) and
registered with the China Clinical Trial Registry (registration
number: ChiCTR2300076299). All patients signed the informed
consent form before participation.
2.2 Procedures
is cross-sectional study design was completed in the
biomechanics laboratory of the Shandong Sport University.
Participants were recruited between Oct. 2023 and May 2024.
Before the biomechanical assessment, participants completed
the International Knee Documentation Committee (IKDC) to
assess knee function. Participants’ demographic information,
surgery information, and dominant limb are shown in Table1.
Limb dominance was determined by which limb they were more
accustomed to using when kicking a ball (Zumsteinetal., 2022).
Participants changed into spandex pants and t-shirts and wore
running shoes provided by the laboratory. ey were allowed
to perform self-selected warm-up activities for 5minbefore
testing. Fiy-three reective markers were placed on the head,
trunk, and limbs, with three marker clusters placed on each
thigh and shank (Figure1). Twenty electrodes were placed
bilaterally on the vastus medialis (VM), vastus lateralis (VL),
rectus femoris (RF), biceps femoris (BF), and semitendinosus (ST)
(Heetal., 2022;DiGiminianietal., 2023).
Following a static calibration trial, participants conducted three
successful trials of a DVJ task, along with three 5-s maximal
voluntary isometric contraction (MVIC) tests for the quadriceps
and hamstrings. For the DVJ task, participants were asked to
jump forward from a 30cm-high box onto force platforms,
and immediately jump as high as possible (Baellowetal., 2020)
(Figure2). Participants landed on the two force plates with both
feet respectively without falling, and all signals were collected which
was considered as a successful trial. Participants were allowed to
swing their arms as needed during jumps. e MVIC test for
quadriceps were performed with participants in sitting with 60° of
knee exion, while hamstrings were performed with 30° of knee
exion in prone position (Kotsifakietal., 2022b). Participants were
given a 1-minrest between trials to reduce the eects of fatigue.
e three-dimensional positions of the reective markers were
captured using 12 infrared cameras at a sampling frequency of
200Hz (Vicon Motion Systems Ltd., Oxford, United Kingdom).
Bilateral ground reaction forces (GRF) data were collected using two
force platforms (AMTI, Inc., Watertown, MA, United States) at a
sampling frequency of 1,000Hz. Electromyographic (EMG) signals
were collected using a wireless surface EMG system (Noraxon,
Arizona, United States) at a sampling frequency of 2000Hz. e
coordinate signals of markers and analog signals of GRF and EMG
data collection were time synchronized using Nexus soware (Vicon
Motion Systems Ltd., Oxford, United Kingdom).
2.3 Data reduction
Raw marker coordinates and GRF data were ltered using a
fourth-order, zero-phase Butterworth lter at a low-pass of 10Hz
(Kimetal., 2015) and 50Hz (Tengetal., 2017), respectively. Knee
joint angles were using a Cardan X-Y-Z sequence of rotations,
dened as the angle between the distal and proximal segments
(Kotsifakietal., 2022b). Knee joint moments were computed
using the inverse dynamics approach (Mausehund and Krosshaug,
2024). Posterior peak GRF (PPGRF) is the rst peak of the
posterior GRF (Daietal., 2015), and peak vertical GRF (PVGRF) is
the maximum vertical GRF in the rst landing-impact phase (time
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Xue etal. 10.3389/fphys.2024.1488001
FIGURE 1
Reective marker positions in the Visual 3D model. (A) view from the front. (B) view from behind.
FIGURE 2
Drop vertical jump (DVJ) task. First landing-impact phase (time between initial contact with the ground and maximum knee exion) of the DVJ task
was analyzed.
between initial contact with the ground and maximum knee exion).
Posterior and vertical GRF and knee jointmoments were normalized
to body weight (kg).
Raw EMG signals for MVIC and dynamic tasks were
ltered with a 20–500Hz bandpass lter (Markströmetal.,
2022), and smoothed using a root-mean-square algorithm
with a 50 milliseconds moving window (Franketal., 2016).
e integral of EMG (IEMG) signals for assessing muscle
activity during the rst landing-impact phase for each muscle
was calculated using the following Equation 1 (Urbanek and
VanDerSmagt, 2016;Baellowetal., 2020):
IEMG =∫t2
t1|X(t)|dt (1)
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t1is initial contact, t2is maximum knee exion, X(t) is the EMG
signal. e mean time of the rst landing-impact phase of the three
DVJ tasks for each participant was used to calculate the IEMG in
the MVIC task.
e dynamic IEMG data were normalized to the MVIC tests,
therefore IEMG data were reported as %MVIC. All data processing
was performed in Visual 3D soware (C-Motion Inc., Germantown,
United States).
2.4 Statistical analysis
Data normality was determined using the Shapiro-Wilk test.
One-way ANOVAs or independent t-tests were used to compare
dierences in participants’ demographic information among
groups. Two-way repeated-measures ANOVAs (limb × group) were
performed for variables of interest to examine the main eects of
limb (dominant vs. nondominant) and group (ACLR-D, ACLR-
ND, and CON), as well as the interaction between limb and group.
Paired and independent t-testswere used to post hoc tests to compare
dierences between limbs and groups, respectively, if no signicant
interaction eect was detected but signicant main eects were
detected. One-way ANOVAs were used to determine the eects
of each independent variable on a given dependent variable if a
signicant interaction eect was detected. e signicant level
was set at α = 0.05. Partial η2(η2
p) was used to indicate the eect
sizes of two-way ANOVAs for the main and interaction eects. e
thresholds for η2
pwere: 0.01–0.06 for small, 0.06–0.14 for medium,
and greater than 0.14 for large eect sizes (Pierceetal., 2004). All
data were statistics in SPSS 26.0 and presented as mean ± SDs.
3 Results
Signicant limb × group interactions were observed for knee
valgus angle (p= 0.019; η2
p= 0.172), knee extension moment (P
< 0.001; η2
p= 0.318), and knee valgus moment (P = 0.027; η2
p=
0.142). post hoc tests demonstrated that the nonsurgical limbs of the
ACLR-Dand ACLR-ND groups had signicantly greaterknee valgus
angle and knee extension moment compared to the surgical limbs,
and the knee valgus moments of the nonsurgical limbs were greater
than the surgical limbs in ACLR-ND group. For the nonsurgical
limbs, the ACLR-ND group exhibited signicantly greater knee
valgus moments compared to the CON group. No any main eects
or interactions were observed in knee exion angle, knee external
rotation angle, and knee internal rotation moment (Table2).
Signicant limb × group interactions were observed for the
muscle activation in VM (P = 0.007; η2
p= 0.203), RF (P = 0.007; η2
p=
0.195), and VL (P = 0.006; η2
p= 0.206). Post hoc tests demonstrated
that the muscle activation of the surgical limbs on VM, RF, and
VL in the ACLR patients and of the nonsurgical limbs on VM and
VL in the ACLR-ND group was signicantly lower than that in
the CON group. e nonsurgical limbs of the ACLR-D group had
signicantly greater muscle activation in VM, RF, and VL compared
to the surgical limbs (Table3).
No signicant limb × group interactions were found for the
muscle activation in BF and ST, while a signicant group eect was
detected for both BF (P < 0.001; η2
p= 0.398) and ST (P < 0.001;
TABLE 2 Knee joint angles and moments at PPGRF during the landing phase in drop vertical jump (DVJ) task (mean ± SD).
ACLR-D ACLR-ND CON P (η2
p)
Nonsurgical Surgical Nonsurgical Surgical Dominant Non-dominant Limb Group Interaction
Knee exion angle (°) 28.4 ± 8.6 30.1 ± 9.0 30.9 ± 8.1 31.6 ± 8.4 31.9 ± 10.0 32.4 ± 9.1 0.314 (0.022) 0.573 (0.023) 0.842 (0.007)
knee valgus angle※(°) −2.9 ± 2.2 −1.4 ± 0.9a−3.1 ± 2.0 −1.5 ± 1.1a−1.7 ± 1.1 −1.9 ± 1.0 - - 0.019 (0.172)
knee external rotation angle※(°) −4.2 ± 3.0 −4.9 ± 4.7 −5.4 ± 3.9 −4.6 ± 3.6 −5.7 ± 4.6 −4.5 ± 3.8 0.519 (0.009) 0.881 (0.005) 0.485 (0.030)
knee extension moment (Nm/kg) 1.36 ± 0.46 1.19 ± 0.36a1.67 ± 0.46b1.21 ± 0.26a1.31 ± 0.26 1.32 ± 0.31 - - <0.001 (0.318)
knee valgus moment※(Nm/kg) −0.14 ± 0.11 −0.13 ± 0.08 −0.25 ± 0.23b−0.11 ± 0.07a−0.11 ± 0.06 −0.12 ± 0.07 - - 0.027 (0.142)
knee internal rotation moment
(Nm/kg)
0.03 ± 0.11 0.02 ± 0.04 0.04 ± 0.09 0.02 ± 0.05 0.03 ± 0.06 0.02 ± 0.02 0.277 (0.025) 0.973 (0.001) 0.916 (0.004)
PPGRF,p eak posterior ground reaction force; ACLR-D, anterior cruciate ligament reconstruction on dominant limb; ACLR-ND, anterior cruciate ligament reconstruction on nondominant limb; CON, control.
※Knee valgus angle, knee external rotation angle and knee valgus momentwere dened as negative numbers.
aSignicant dierence within-group.
bSignicant dierence compared with CON, group.
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TABLE 3 Landing-impact time and muscle activation during the landing phase in drop vertical jump (DVJ) task (mean ± SD).
ACLR-D ACLR-ND CON P (η2
p)
Nonsurgical Surgical Nonsurgical Surgical Dominant Non-
dominant
Limb Group Interaction
landing-impact time
(s)
0.278 ± 0.048 0.274 ± 0.053 0.277 ± 0.050 0.281 ± 0.055 0.294 ± 0.052 0.296 ± 0.051 0.904 (0.001) 0.510 (0.028) 0.266 (0.055)
VM (%MVIC) 113.6 ± 66.7 64.3 ± 40.1ab 69.9 ± 35.6a63.1 ± 36.5a154.8 ± 43.9 170.5 ± 66.5 - - 0.007 (0.203)
RF (%MVIC) 84.3 ± 62.0 45.3 ± 32.8ab 63.3 ± 26.0 42.8 ± 29.4a100.5 ± 27.4 108.9 ± 43.1 - - 0.007 (0.195)
VL (%MVIC) 94.5 ± 52.3 53.1 ± 34.4ab 58.4 ± 35.9a59.5 ± 42.4a132.2 ± 45.3 144.8 ± 51.3 - - 0.006 (0.206)
BF (%MVIC) 15.9 ± 9.1a13.3 ± 8.7a10.9 ± 4.9a15.9 ± 8.6a30.3 ± 18.5 25.6 ± 7.9 0.682 (0.004) <0.001 (0.398) 0.095 (0.101)
ST (%MVIC) 13.7 ± 8.1a15.8 ± 9.0ab 11.9 ± 4.8a20.0 ± 13.0ab 25.5 ± 8.2 30.6 ± 12.3b0.002 (0.213) <0.001 (0.382) 0.283 (0.058)
VM, vastus medialis; RF, rectus femoris; VL, vastus lateralis; BF, biceps femoris; ST, semitendinosus; MVIC, maximal voluntary isometric contraction; ACLR-D, anterior cruciate ligament reconstruction on dominant limb; ACLR-ND, anterior cruciate ligament
reconstruction on nondominant limb; CON, control.
aSignicant dierence compared with CON, group.
bSignicant dierence within-group.
η2
p= 0.382), as well as a main eect for limb in ST (P = 0.002;
η2
p= 0.213). Post hoc tests demonstrated that the BF and ST
activation in ACLR patients were signicantly smaller compared to
the CON group. Additionally, the nonsurgical limbs of the ACLR
patients exhibited signicantly smaller ST activation compared
to the surgical limbs. No signicant dierences between or
within groups were detected in the landing-impact time during
the DVJ task (Table3).
No signicant limb × group interactions were detected on any
muscle activation in MVIC tasks. Signicantgroup main eects were
observed only in muscle activation of VL (P = 0.016; η2
p= 0.161)
and BF (P = 0.003; η2
p= 0.219) in the MVIC task. Post hoc tests
demonstrated that ACLR patients had signicantly lower activation
of both VL and BF in bilateral limbs than the CON group (Table4).
Signicant limb × group interactions were observed for PPGRF
(P = 0.006; η2
p= 0.199) and PVGRF (P = 0.029; η2
p= 0.140). Post
hoc tests demonstrated that the nonsurgical limbs of the ACLR-D
and ACLR-ND groups had signicantly greater PPGRF and PVGRF
compared to the surgical limbs. For the nonsurgical limbs, the
ACLR-ND group exhibited signicantly greater PPGRF and PVGRF
compared to the CON group. Additionally, the ACLR-ND group
showed greater PPGRF in the nonsurgical limbs compared to the
ACLR-D group (Figure3).
4 Discussion
e results of this study partially support our rst hypothesis,
indicating that the nonsurgical limbs exhibited greater GRFs and
knee joint moments compared to the surgical limbs in both ACLR-
D and ACLR-ND groups, with the exception of quadriceps and
hamstring muscle activation. e results of this study demonstrated
that the nonsurgical limbs of ACLR patients exhibited greater
PPGRF and PVGRF compared to surgical limbs in the DVJ task.
ese ndings were consistent with previous studies that have
shown ACLR patients reduce the weight bearing of the surgical
limbs during exercises (Songetal., 2023;Baumgartetal., 2017)
due to quadriceps inhibition and weakness (Palmieri-Smithetal.,
2019;Pietrosimoneetal., 2022). is self-protective mechanism
(Baumgartetal., 2017) reduces the impact of GRF on the surgical
knee, potentially mitigating the risk of further injury. e current
study results suggested a possible change in the movement
pattern and neuromuscular control strategy used by ACLR patients
when performing the DVJ, which may be characterized by an
altered landing strategy. Despite the synchronous movement of
both limbs during the DVJ, ACLR patients actively shi their
center of gravity towards the nonsurgical limbs, resulting in
greater GRF being absorbed by the nonsurgical limbs, which may
contribute to an increased risk of ACL injury. Previous studies
have shown that greater GRF can increase tibiofemoral joint
compression forces, which is a known risk factor for ACL injury
(Meyeretal., 2008;Bodenetal., 2010). erefore, these ndings
suggested that patients in both the ACLR-D and ACLR-ND groups
may be at an increased risk of ACL injury in their nonsurgical
limbs compared to the surgical limbs during DVJ task, potentially
due to the altered movement patterns and neuromuscular control
strategies.
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Xue etal. 10.3389/fphys.2024.1488001
FIGURE 3
PPGRF (A) and PVGRF (B) in the rst landing-impact phase of the DVJ task. PPGRF, peak posterior ground reaction force. PVGRF, peak vertical ground
reaction force. NS, nonsurgical limb. S, surgical limb. D, dominant limb. ND, nondominant limb. ACLR-D, anterior cruciate ligament reconstruction on
dominant limb. ACLR-ND, anterior cruciate ligament reconstruction on nondominant limb. CON, control. ∗Signicant dierence compared with CON
group. # Signicant dierence compared with ACLR-ND group. § Signicant dierence within-group.
e current study revealed no signicant dierences in knee angles
and moments at PPGRF between the dominant and nondominant
limbs of healthy individuals during the DVJ task. is may suggest
that ACLR patients have no inherent dierences in the bilateral
limbs prior to the ACL injury. Conversely, our results indicated that
ACLR patients demonstrated greater knee valgus angles and extension
moments in their nonsurgical limbs compared to their surgical limbs,
as well as the ACLR-ND patients also exhibited greater knee valgus
moments in their nonsurgical limbs. is is consistent with previous
studies that have reported reduced surgical knee loading in patients
with ACLR (Sritharanetal., 2020;Kotsifakietal., 2022b;Bühletal.,
2023). e reason for these results may be an adaptive change in
the landing strategy of ACLR patients. ACLR patients may rely more
heavily on their nonsurgical limbs due to decreased VM, VL and RF
muscle strength, impaired knee proprioception, and reduced stability
in the surgical limbs (Howellsetal., 2011;Arumugametal., 2021),
which can lead to an adaptive change in their landing strategy. is
also validated that asymmetry of knee moments is associated with
asymmetric GRF, which can lead to altered movement patterns and
increased risk of injury (Daietal., 2014). As results of these adaptive
changes in landing strategy, ACLR patients may be at an increased risk
of ACL injury in their nonsurgical limbs, particularly during dynamic
movements that involve landing.
e results of this study partially support our second hypothesis
that the nonsurgical limbs in the ACLR-ND patients exhibited greater
knee extension and valgus moments, as well as greater GRFs compared
to CON group, which may contribute to an increased risk of ACL
injury. Furthermore, in the nonsurgical limbs, the ACLR-ND patients
demonstrated greater PPGRF compared to the ACLR-D patients,
as well as greater GRFs, and greater knee valgus and extension
moments compared to the CON group. ese dierences did not
exist between the ACLR-D and CON groups. ese were similar to
previous studies on single-leg jump (Mohammadietal., 2013), side
cut (Warathanagasameetal., 2023), and stair walking (Zabalaetal.,
2013) tasks. However, in contrast with our results, neither Rushetal.
(2024) nor Chenetal. (2024) observedgreater GRF and knee extension
and valgus moments in the nonsurgical limbs compared to the healthy
individuals in single-leg jump or DVJ tasks. e inconsistent results
may be attributed to the fact that these studies did not account for
the potential inuence of limb dominance on movement patterns aer
ACLR. Notably, the nonsurgical limb was the dominant limb in the
ACLR-ND patients in the current study, which may have inuenced
their movement patterns and neuromuscular control strategies during
the landing task. Compared to ACLR-D, the ACLR-ND patients may
have been more inclined to use a protective pattern, characterized by
increased knee extension and valgus moments, on the nonsurgical
limbs during the landing phase, and felt more condent with aggressive
landings. However, for ACLR-ND patients, this protective movement
pattern may have unintended consequences, as the increased knee
loading on the nonsurgical limbs may actually increase the risk of ACL
injury, rather than reducing it.
Contrary to our initial hypothesis, no signicant dierences in
muscleactivation levelsofthequadricepsandhamstringswereobserved
in the nonsurgical limbs between ACLR-ND and ACLR-D patients.
However, our study revealed that muscle activation in the VM and VL
of the nonsurgical limbs was signicantly decreased during DVJ task
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Xue etal. 10.3389/fphys.2024.1488001
TABLE 4 Muscle activation during the maximal voluntary isometric contraction (MVIC) task (mean ± SD).
ACLR-D ACLR-ND CON P (η2
p)
Nonsurgical Surgical Nonsurgical Surgical Dominant Non-
dominant
Limb Group Interaction
VM_MVIC (μv·s) 54.0 ± 12.4 52.2 ± 11.5 60.0 ± 14.8 53.0 ± 19.4 66.3 ± 20.6 63.3 ± 25.4 0.106 (0.055) 0.101 (0.093) 0.657 (0.018)
RF_MVIC (μv·s) 62.4 ± 9.3 60.2 ± 9.1 67.1 ± 18.5 63.1 ± 15.4 68.5 ± 14.9 67.2 ± 16.1 0.189 (0.036) 0.331 (0.046) 0.852 (0.007)
VL_MVIC (μv·s) 55.3 ± 17.6a57.8 ± 16.0a57.4 ± 14.1a55.9 ± 8.0a67.7 ± 8.7 66.3 ± 8.7 0.946 (0.001) 0.016 (0.161) 0.475 (0.031)
BF_MVIC (μv·s) 65.4 ± 9.6a64.9 ± 13.8a66.8 ± 6.2a68.4 ± 8.1a78.8 ± 21.5 79.8 ± 14.1 0.659 (0.004) 0.003 (0.219) 0.854 (0.007)
ST_MVIC (μv·s) 78.3 ± 13.6 80.0 ± 12.2 79.9 ± 16.0 77.4 ± 8.7 83.3 ± 15.0 81.3 ± 16.4 0.687 (0.003) 0.601 (0.021) 0.714 (0.014)
VM, vastus medialis; RF, rectus femoris; VL, vastus lateralis; BF, biceps femoris; ST, semitendinosus; MVIC, maximal voluntary isometric contraction; ACLR-D, anterior cruciate ligament reconstruction on dominant limb; ACLR-ND, anterior cruciate ligament
reconstruction on nondominant limb; CON, control.
aSignicant dierence compared with CON group.
in ACLR-ND patients compared to CON group, in addition to reduced
activation of the quadriceps and hamstrings of the surgical limbs.
Additionally, muscle activation in BF and ST of the nonsurgical limbs
was signicantly lower during DVJ task in both ACLR-ND and ACLR-
D patients compared to CON group. ese results were consistent with
literatures,whichalsoreported lowerbilateralquadricepsandhamstring
activation in ACLR compared to healthy controls (Alanazietal., 2020;
Einarssonetal.,2021).ismaybe attributedtoreducedquadricepsand
hamstring muscle strength and neuromuscular inhibition (Palmieri-
Smithetal., 2019;Pietrosimoneetal., 2022). Additionally, a recent
study reported that increased quadriceps and hamstring activation
was associated with reduced knee exion angle (Malfaitetal., 2016).
erefore, ACLR patients may attempt to obtain a greater knee
exion angle to reduce impact of GRF by reducing bilateral muscle
activation. Lower quadriceps and hamstring activation was associated
with reduced dynamic knee stability, which may be a contributing
factor to the increased risk of ACL injury (Ortizetal., 2014;Palmieri-
Smithetal., 2019;Wangetal., 2023). ese results combined together
suggest that abnormal quadriceps and hamstring activation in ACLR-
ND patients is associated with an increased risk of ACL injury. In
summary, our study revealed signicant dierences in quadriceps
and hamstring activation levels between dominant and nondominant
limbs in ACLR patients. ese ndings emphasized the need for
personalized rehabilitation programs that take into account limb
dominance to optimize outcomes and reduce the risk of further
injury in ACLR patients.
ere are several limitations in our study. Firstly, all participants
weremale, and sincegenderdierences inknee valgusangles,and GRFs
during landing (Seymoreetal., 2019;Peeblesetal.,2020) may aect the
applicability of our results to females, future studies should investigate
the eects of limb dominance on biomechanics in female ACLR
patients. Secondly, we only analyzed ACLR patients with autologous
hamstring gras. Since there is an eect of dierent gra types on knee
biomechanics (Wangetal., 2018;Yangetal., 2020), further studies in
patients with other gra types are needed. ird, we did not collect
muscle strength, proprioception from the participants. Previous studies
have indicated thatmusclestrength,proprioceptionaectknee function
and athletic performance (Maetal., 2022;Changetal., 2024). Future
studies should investigate the eect of limb dominance on functional
outcomes. Fourth, we only investigated biomechanical characteristics
in the DVJ task, and future studies should investigate the eects of limb
dominance on biomechanics during variousmovement tasks, including
single-leg jumps and side-cutting maneuvers. Fih, we conducted
a cross-sectional analysis, which did not allow us to examine the
longitudinal eects of limb dominance on biomechanics aer ACLR.
e long-term eects of limb dominance on biomechanics aer ACLR
remain unclear and warrant further investigation.
5 Conclusion
e nonsurgical limbs of ACLR patients may suer an
increased risk of ACL injury due to altered landing mechanics and
neuromuscular control strategies compared to the surgical limbs.
Additionally, limb dominance inuences movement patterns and
neuromuscular control during DVJ task, the nonsurgical limbs of
the ACLR-ND might be at higher risk of ACL injury compared to
the ACLR-D group. Given that limb dominance aects movement
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Xue etal. 10.3389/fphys.2024.1488001
patterns, the impact of limb dominance should be considered in the
rehabilitation of ACLR patients for better return to sport.
Data availability statement
e original contributions presented in the study are included in
the article/supplementary material, further inquiries can be directed
to the corresponding authors.
Ethics statement
e study was approved by the Ethics Committee of Sports
Science of Shandong Sports University (approval number: 2023004)
and registered with the China Clinical Trial Registry (registration
number: ChiCTR2300076299). e studies were conducted in
accordance with the local legislation and institutional requirements.
e participants provided their written informed consent to
participate in this study. Written informed consent was obtained
from the individual(s) for the publication of any potentially
identiable images or data included in this article.
Author contributions
BX: Writing–review and editing, Writing–original dra,
Visualization, Validation, Soware, Project administration,
Methodology, Investigation, Formal Analysis, Data curation,
Conceptualization. XY: Writing–review and editing, Validation,
Supervision, Methodology, Investigation. XW: Writing–review and
editing, Supervision, Project administration, Methodology. CY:
Methodology, Funding acquisition, Writing–review and editing. ZZ:
Supervision, Resources, Project administration, Writing–review and
editing, Methodology.
Funding
e author(s) declare that nancial support was received for
the research, authorship, and/or publication of this article. is
work was supported by the General Project of Jiangsu Provincial
Collaborative Innovation Center of “Exercise and Health” (JSCIC-
GP21009).
Acknowledgments
e authors would like to thank Yu Song, associate professor at
the University of Kansas, and Jianbin Zhao, Yingce Yao, Jing Wu,
Yuting Zhao, Kexin Yang, and Mengyu Liu, graduate students at the
Shandong Sports University, for participating in manuscript revision
or data collection for this work.
Conict of interest
e authors declare that the research was conducted in the
absence of any commercial or nancial relationships that could be
construed as a potential conict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their aliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or claim
that may be made by its manufacturer, is not guaranteed or endorsed
by the publisher.
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