Review
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►► Additional material is
published online only. To view
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​
bjsports-​2018-​099918).
1
Department of Rehabilitation,
Aspetar Orthopaedic and Sports
Medicine Hospital, Doha, Qatar
2
Department of Movement
Sciences, Human Movement
Biomechanics Research Group,
KU Leuven, Leuven, Belgium
Correspondence to
Mrs Argyro Kotsifaki,
Department of Rehabilitation,
Aspetar Orthopaedic and Sports
Medicine Hospital, Doha 29222,
Qatar;
​argyro.​kotsifaki@a​ spetar.​com
Received 7 August 2018
Revised 8 April 2019
Accepted 10 April 2019
Published Online First
29 May 2019
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Kotsifaki A,
Korakakis V, Whiteley R,
et al. Br J Sports Med
2020;54:139–153.
Measuring only hop distance during single leg hop
testing is insufficient to detect deficits in knee function
after ACL reconstruction: a systematic review and meta-­
analysis
Argyro Kotsifaki ‍ ‍ ,1,2 Vasileios Korakakis,1 Rod Whiteley,1 Sam Van Rossom,2
Ilse Jonkers2
ABSTRACT
Objective  To systematically review the biomechanical
deficits after ACL reconstruction (ACLR) during single
leg hop for distance (SLHD) testing and report these
differences compared with the contralateral leg and
with healthy controls.
Design  Systematic review with meta-­analysis.
Data sources  A systematic search in Pubmed (Ovid),
EMBASE, CINAHL, Scopus, Web of Science, PEDro,
SPORTDiscus, Cochrane Library, grey literature and
trial registries, was conducted from inception to 1 April
2018.
Eligibility criteria for selecting studies  Studies
reporting kinematic, kinetic and/or electromyographic
data of the ACLR limb during SLHD with no language
limits.
Results  The literature review yielded 1551 articles
and 19 studies met the inclusion criteria. Meta-­
analysis revealed strong evidence of lower peak knee
flexion angle and knee flexion moments during landing
compared with the uninjured leg and with controls.
Also, moderate evidence (with large effect size) of
lower knee power absorption during landing compared
with the uninjured leg. No difference was found in
peak vertical ground reaction force during landing.
Subgroup analyses revealed that some kinematic
variables do not restore with time and may even
worsen.
Conclusion  During SLHD several kinematic and
kinetic deficits were detected between limbs after
ACLR, despite adequate SLHD performance. Measuring
only hop distance, even using the healthy leg as a
reference, is insufficient to fully assess knee function
after ACLR.
PROSPERO trial registration number
CRD42018087779.
INTRODUCTION
ACL injury is associated with a high injury burden in
terms of days lost from sports participation.1 Despite
current advances in ACL reconstruction (ACLR)
techniques, more than a third of those who receive
surgery are unable to return to preinjury levels of
activity.2 In addition, reinjury rate after ACLR is
high with around 20% of young athletes reinjuring
the operated side or suffering an ACL rupture in the
contralateral (healthy) knee within a year of returning
to play.3
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918
After an ACL reconstruction, lower limb biome-
chanics are altered, both in the frontal (increased hip
adduction and knee valgus) and the sagittal plane
(decreased hip extension and knee flexion moments),
and in both legs.4 These movement patterns and
loading strategies are associated with increased risk
of a non-­contact ACL injury.5 6
While detailed biomechanical evaluations using
advanced techniques such as three-­ dimensional
motion analyses, force plate measurements and elec-
tromyography (EMG) are available in the research
context, the clinical criteria to determine readiness
for return to play (RTP) typically rely on a strength
test and a hop test battery to assess functional leg
symmetry. Single leg hop for distance (SLHD) is
the most frequently reported functional test.7 A Leg
Symmetry Index (LSI) of >90% is recommended as
copyright.
a cut-­off point indicating safe RTP.8 Athletes who do
not meet the discharge criteria before returning to
professional sport have a four times greater risk of
sustaining an ACL graft rupture compared with those
who met all RTP criteria.9
However, as deficits have also been documented
in the contralateral leg after surgery, the use of a
symmetry index that compares against the uninjured
leg may not be optimal.10 11 Additionally, measuring
hop distance or LSI is not informative of the move-
ment quality nor recovery of knee function after
ACLR.
Therefore, the objective of this systematic review
and meta-­analysis was to identify deficits in lower
limb biomechanics during SLHD after ACLR. In this
context, the effectiveness of SLHD in the decision for
a safe RTP was evaluated.
Methods
We adhered to the Preferred Reporting Items for
Systematic reviews and Meta-­ Analyse (PRISMA)
guidelines12 in search strategy and reporting, and
followed guidance of the Cochrane Handbook for
Systematic Reviews13 for the preparation of this
review. The protocol was registered in the PROS-
PERO database (http://www.​crd.​york.​ac.​uk/​PROS-
PERO) (CRD42018087779).
Search methods
A systematic search of eight electronic data-
bases (Pubmed (Ovid), EMBASE, CINAHL,
Scopus, Web of Science, PEDro, SPORTDiscus
   1 of 16
 Review
and Cochrane Library) was conducted (AK) from inception
to 1 April 2018. Grey literature was searched via OpenGrey,
as well as the following trial registries: EU Clinical Trials
Register, Clinical ​Trials.​
gov and WHO International Clin-
ical Trials Registry Platform. The strategy used a range of
keywords in four categories which were combined: (1) ACL
(2) Reconstruction. (3) Biomechanics. (4) Hop test (online
supplementary file 1).
Study selection
No limit on language or publication year was imposed to mini-
mise language and publication bias. No minimal duration of
follow-­up was considered for inclusion. Articles were imported
into EndNote V.X7 (Clarivate Analytics Software, Philadel-
phia, Pennsylvania’s, USA) and duplicates were removed. Two
reviewers (AK and VK) independently reviewed the articles
by title and abstract using predetermined eligibility criteria.
The full texts of potentially eligible studies were retrieved
and independently screened. Disagreements were resolved
by consensus, or by consulting a third reviewer (RW). Refer-
ence lists were also screened (backward citation tracking and
the ‘similar function’ within the PubMed database was used)
along with the authors’ personal databases.14
Inclusion criteria:
►► Studies examining: kinematic, kinetic and/or EMG data of
the ACLR knee and the asymptomatic controls during SLHD
test.
►► Men and women with ACL rupture managed with recon-
struction using any type of graft.
►► Observational study designs (prospective cohort studies, case-­
control studies and cross-­sectional studies) or randomised
clinical trials with comparison to a control group or to
contralateral uninjured side at baseline or at follow-­up.
►► No restriction was placed on: age, time since surgery or
recruitment method.
Exclusion criteria
►► Animal or cadaveric studies.
►► Abstracts, reviews, case series, case studies, opinion articles
or conference proceedings.
►► Studies focusing on other tasks such as drop-­jumps, jumping,
pivoting and any submaximal tests.
Assessment of methodological quality
Two independent reviewers (AK and VK) assessed the method-
ological quality of included studies using a modified version of
the Downs and Black checklist15 as previously described.16 17
The modified version consists of 16 items with a total possible
score of 19. A score of ≥75% indicates high quality (HQ),
60%–74% indicates moderate quality (MQ) and ≤60% low
quality (LQ).17 Discrepancy between reviewers at initial rating
was resolved through discussion, otherwise, a third reviewer
(RW) was consulted.
Data extraction
Data from included studies were extracted independently by
two reviewers (AK and VK). Extracted details from all studies
included: authors, year of publication, study design, demo-
graphics (age, height, weight, graft type, time since surgery,
numbers of participants), primary (kinematics, kinetics, EMG)
and any secondary outcomes. Primary outcomes were cate-
gorised and reported according to the phase of the hop test;
propulsion phase (before initial contact (IC)), IC (discrete
point) and landing phase (after IC). As there was heterogeneity
2 of 16
Br J Sports Med: first published as 10.1136/bjsports-2018-099918 on 29 May 2019. Downloaded from http://bjsm.bmj.com/ on August 8, 2020 at Vrije Universiteit Bibliotheek. Protected by
in the definitions for these phases, propulsion was defined as
the time between maximum knee flexion and toe-­off, while
landing was the time between IC and maximum knee flexion.
If insufficient data were reported in the published article
or supplementary material provided, the corresponding
author was contacted to request further data. When it was
not possible to retrieve data, results were not included in the
meta-­analysis and were reported descriptively. Where studies
reported results of the group of interest (ACLR) during SLHD
test but examining different situations, these were included
only for qualitative analysis. Where included studies reported
participants’ characteristics from another published study, the
data from that study were used. If necessary, authors were
contacted for further clarification to confirm eligibility and
facilitate accurate data extraction.
Data analysis
Extracted data were imported to Review Manager V.5.3
(RevMan) (Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014) for analysis. Data were anal-
ysed by limb using two comparisons: (1) The ACLR limb
compared with the contralateral uninjured limb. (2) The
ACLR limb compared with a healthy control group. Means
and SDs from each variable of interest were used to calculate
standardised mean differences (SMDs) with associated 95%
CIs in a random-­effects model. Cohen’s criteria were used
to interpret pooled SMD: large effect ≥0.8, moderate effect
0.5–0.8 and small effect 0.2–0.5.18 The I2 Index was used to
assess statistical heterogeneity between pooled results and
values were interpreted as: low ≤50%; moderate=51%–74%
copyright.
and large ≥75%.19 Kinematic results were also analysed and
reported as mean differences (MDs) for clinical applicability.20
Where SE or CIs were reported, we used the calculator in
Review Manager to estimate SD. Joint moments reported as
internal were arbitrarily converted to external moments for
consistency (eg, internal extension moment=external flexion
moment). Where comparing with the control group and if
bilateral results were mentioned (dominant – non-­dominant),
we used data from the dominant leg. When more than one
study reported results for the same variable,21 data were
pooled in a meta-­analysis, otherwise a qualitative synthesis was
conducted. All studies eligible for meta-­analysis were ordered
in forest plots based on time since surgery.21 Sensitivity and
subgroup analyses were conducted, where applicable. Levels
of evidence were based on recommendations by van Tulder
et al22 in alignment with previous reviews of similar included
study types23 24 and defined as:
►► Strong: consistent results from multiple studies, including a
minimum of two HQ studies, which are statistically homo-
geneous (I2 <50%).
►► Moderate: consistent results from multiple studies, including
at least one HQ study, which are statistically heterogeneous
(I2 >50%); or from multiple MQ/LQ studies which are
statistically homogenous (I2 <50%).
►► Limited: based on results from multiple MQ and LQ studies
which are statistically heterogeneous (I2 >50%); or two
MQ/LQ studies statistically homogeneous (I2 <50%); or
from one HQ study.
►► Very limited: based on results derived from one MQ/LQ
study.
►► No evidence: if the pooled data were not statistically signifi-
cant and from multiple statistically heterogeneous (I2 >50%)
studies with inconsistent findings.
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918

Figure 1  PRISMA study selection flow chart. PRISMA, Preferred
Reporting Items for Systematic reviews and Meta-­Analyses.
Results
Search results
The electronic search conducted on 1 April 2018, yielded
a total of 1551 potentially relevant articles. After duplicate
removal, 756 articles were screened by title and abstract. The
full texts of 60 articles were assessed for eligibility according
to the inclusion/exclusion criteria. Finally, 19 articles25–43 met
the inclusion criteria of the present review (figure 1).
Characteristics of the included studies
Eighteen of the 19 included studies had a cross-­ sectional
design25–32 34–43 and one had a prospective design.33 A total
of 624 ACLR patients (424 men, 200 women; mean age 30
years) as well as 315 controls (208 men, 107 women; mean
age 27.6 years) were included in the review (table 1). In 13
studies, biomechanical outcomes were compared with the
contralateral leg and in 12 studies with a control group.
Sixteen studies25 27–32 35–43 reported kinematics of the SLHD
test, eight studies26 30 33 35 36 39 41 42 reported kinetics and four
studies25 27 30 34 reported EMG data. Only two studies27 30
simultaneously collected kinematics, kinetics and EMG, but
one27 used a mixed group of healthy and ACLR patients and
compared different landing strategies, whereas another30
reported kinematics and kinetics in a mixed group of healthy
and ACLR subjects (due to missing data). Fourteen studies
were eligible for meta-­ analysis. Two studies31 37 made a
different analysis of the same data set of a study38 which was
used in the meta-­analysis, thus those two were included only
for qualitative analysis. Also, their sample population was not
included in the total ACL patients and controls. Addition-
ally, two studies42 43 used the same data set and the sample
calculated only once. Two studies did not compare with the
contralateral leg or a healthy control group but investigated
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918
Review
Br J Sports Med: first published as 10.1136/bjsports-2018-099918 on 29 May 2019. Downloaded from http://bjsm.bmj.com/ on August 8, 2020 at Vrije Universiteit Bibliotheek. Protected by
different landing strategies.27 32 Two corresponding authors
provided additional information regarding their studies.29 42
Data from one study34 could not be exported and the results
were excluded from meta-­analysis. A summary of the included
studies is presented in table 2. Extracted data include activity
level, knee function score and LSI of the hopped distance.
Assessment of methodological quality
The κ correlation coefficient was 0.91 for the agreement
between the two reviewers for methodological quality assess-
ment. Quality score ranged from 10 to 17 (maximum score
19) with an average score of 14 (table 2 and online supple-
mentary file 2). Justification for scoring for each criterion
is presented in online supplementary file 3. There were 9
HQ,28 29 32 34 36 38 39 41 43 6 MQ26 27 30 31 37 40 and 4 LQ25 33 35 42
studies. All included studies reported their aims/hypotheses,
main outcomes, participant characteristics and used valid and
reliable assessment and outcome tools. Only two studies29 40
attempted to blind one of the assessors. The most frequent
sources of potential bias were: source of population of the
groups (n=14), no or limited adjustment for potential
confounders (n=12) and no power analysis (n=10).
Quantitative synthesis: meta-analysis
Fourteen of the 19 studies were eligible for meta-­
analysis.25 26 28–30 33 35 36 38–43 Kinematic, kinetic and EMG
pooled results are presented in figures 2–5. Tables 3 and 4
provide a summary of the evidence. Kinematic results that
were analysed also as MDs are presented in online supple-
mentary file 4.
copyright.
Kinematics
Sagittal plane: comparison to contralateral leg
During propulsion, pooled data suggested strong evidence of
a small effect for less peak knee flexion angle38 41 43 and less
knee range of motion (ROM)35 38 41 in the ACLR leg than the
contralateral leg. Also, strong evidence indicated no difference
for peak hip flexion41 43 and moderate evidence of a small
effect for lower hip flexion ROM.35 41 Moderate evidence of
a small effect for lower peak ankle dorsiflexion41 43 and lower
ankle dorsiflexion ROM35 41 was found. At IC, pooled results
showed strong evidence of no difference between limbs for
knee flexion.29 38 40 41 During landing, pooled data demon-
strated strong evidence of a small effect for the following:
lower peak knee flexion,28 29 38–41 43 lower knee flexion
ROM29 35 38 40 and lower peak ankle dorsiflexion41 43 in the
ACLR leg compared with the contralateral leg. No difference
was found for peak hip flexion39 41 43 (figures 2 and 3; table 3).
Sagittal plane: comparison to healthy controls
During propulsion, pooled data revealed strong evidence of
a small effect for less peak knee flexion38 41 and less knee
flexion ROM38 41 for the ACLR group. At IC, there was strong
evidence of no difference for peak knee flexion.38 41 During
landing, pooled data showed strong evidence of a small effect
for lower peak knee flexion angle28 38 39 41 and for less knee
flexion ROM26 36 38 in ACLR patients (figure 2; table 3).
Frontal plane: comparison to contralateral leg
Pooled data provided strong evidence of no difference for knee
adduction in the ACLR leg at IC.29 38 41 During landing, pooled
data showed strong evidence of a small effect for lower peak
3 of 16
4 of 16
Table 1  Summary of study and participants features and characteristics
Author / D & B Score Sample size (male/ Source of
Review

study design (max 19) Time post-­ACLR ±SD Graft female) Age (years)±SD Weight (kg) ±SD Height (cm) ±SD Test Data collection funding
Bryant et al25 11 PT: 15.1±5.0 m PT: 14 PT: 14 (M) PT: 30.9±7.3 PT: 87.1±19.6 PT: 180.2±4.7 Max distance EMG (Quantec) UTD
Cross-­sectional HS: 14.2±4.5 m HS: 13 HS: 13 (M) HS: 22.9±3.8 HS: 79.4±7.3 HS: 177.6±5.1 barefoot
C: 22 (M) C: 29.0±8.2 C: 78.6±14.4 C: 178.5±6.2
Button et al26 13 13.5±9 m HS: 21 ACLR: 21 (16M/5F) ACLR: 29.1±9 ACLR: 80.1±9.5 ACLR: 173±7 Max distance Eight cameras VICON Yes
Cross-­sectional C: 21 (12M/9F) C: 26.8±7.7 C: 77.6±19.6 C: 175±13 250 Hz
Kistler 1000 Hz
Chen et al27 14 36±14 m PT: 36 ACLR: 50 (M) ACLR: 28±6 ACLR: 79±10 ACLR: 176±6 Max distance Six cameras VICON Yes
Cross-­sectional HS: 14 BK: 26 (M) BK: 21±2 BK: 78±10 BK: 181±7 200 Hz
C: 31 (M) C: 24±3 C: 66±10 C: 173±6 Kistler 1000 Hz
Eight channel AMT-8
Bortec EMG 1000 Hz
Engelen-­van Melick 16 PT-­M: 63.5±23.3 m PT: 47  PT-M­ : 24 PT-­M: 36.9±8.9 PT-­M: 85.3±11.3 PT-­M: 183±8 Max distance 2D video (analysed with UTD
et al28 HS-­M: 41.1±13.5 m HS: 50  HS-­M: 27 HS-­M: 37.6±9.8 HS-­M: 87.4±12.5 HS-­M: 183±8 Templo)
Cross-­sectional PT-­F: 64.8±25.3 m  C-­M: 22 C-­M: 35.5±10.6 C-­M: 79.6±9.5 C-M­ : 181±6
HS-­F: 52.0±20.6 m  PT-F­ : 23 PT-­F: 36.0±11.0 PT-­F: 68.7±14.5 PT-­F: 172±8
 HS-­F: 23 HS-­F: 33.5±10.0 HS-­F: 68.8±15.3 HS-­F: 171±7
 C-­F: 22 C-­F: 31.5±11.9 C-­F: 67.2±11.1 C-F­ : 170±5
Gokeler et al30 13 27±1.5 w PT ACLR: 9 (6M/3F) ACLR: 28.4±9.7 NR NR Max distance Two cameras OPTOTRAK UTD
Cross-­sectional C: 11 (8M/3F) C: 26.3±5.5 Arms behind back 150 Hz
Force plate 750 Hz
EMG PORTI 800 Hz
Gokeler et al29 15 IF: 22.6±16.9 w IF: 2 PT/6 HT IF: 8 (4M/4F) IF: 23.75±4.46 IF: 73.75±10.32 IF: 180.1±7.53 Max distance Two video cameras Canon No funding
Cross-­sectional EF: 28.0±16.7 w EF: 3 PT/5 HT EF: 8 (5M/3F) EF: 22.63±6.02 EF: 76.50±12.02 EF: 181.25±7.70
Hebert-­Losier et al31 12 20 years PT and/or ACLR: 33 (21M/12F) ACLR: 46±5 BMI: Max distance Eight cameras Qualisys  
Cross-­sectional synthetic C: 33 (21M/12F) C: 47±5 ACLR: 27±3 Hands chest 2400 Hz
C: 25±3 barefoot (Custom-­made force plate
1200 Hz)
Letchford et al32 16 6.2±0.6 m HS ACLR: 30 (24M/6F) ACLR: 30.9±8.3 ACLR: 80.3±14.4 ACLR:175±8 Max distance Two digital video cameras Yes
Cross-­sectional C: 30 (21M/9F) C: 27.9±5.3 C: 75.6±14.1 C: 175±9 Canon 25 Hz
Moya-­Angeler et al33 10 3 m / 6 m / 12 m HS:74 74 (M) 34±9 843 n±20.32   Max distance 2 Kistler Yes
Prospective Hands-­free
Nyland et al34 16 5.2±2.9 years Allogr: 65 ACLR: 65 (32M/33F) G1: 31.1 G1: 76.8 G1: 176.5 Max distance 4-­channel Noraxon EMG UTD
Cross-­sectional G2: 34.7 G2: 76.8 G2: 172.8 1000 Hz
G3: 38.8 G3: 79.7 G3: 172.1
Orishimo et al35 11 7.2±2.7 m PT 13 (9M/4F) 33±10 72.3±11.9 174.5±9.4 Max distance Five cameras Qualisys UTD
Cross-­sectional Hands-­free 60 Hz
Kistler 960 Hz
Roos et al36 15 7–36 m HS: 23 ACLR: 23 (19M/4F) ACLR: 28±9 ACLR: 79.0±10.1 ACLR: 174±6 Max distance Eight cameras VICON Yes
Cross-­sectional C: 20 (11M/9F) C: 29±8 C: 74.8±16.5 C: 174±11 250 Hz
Kistler 1000 Hz
Srinivasan et al37 14 20 years 19 PT+synthetic ACLR: 33 (21M/12F) ACLR: 45.6±4.5 ACLR: 83.0±15.6 ACLR: 174.0±9.1 Max distance Eight cameras Qualisys Yes
Cross-­sectional nine synthetic C: 33 (21M/12F) C: 46.7±5.0 C: 77.4±14.9 C: 176.4±9.8 Hands chest 2400 Hz
5 PT (Custom-­made force plate
1200 Hz)
Tengman et al38 17 20 years 19 PT+synthetic ACLR: 33 (21M/12F) ACLR: 45.6±4.5 ACLR: 83.0±15.6 ACLR: 174.0±9.1 Max distance Eight cameras Qualisys Yes
Cross-­sectional nine synthetic C: 33 (21M/12F) C: 46.7±5.0 C: 77.4±14.9 C: 176.4±9.8 Hands chest 2400 Hz
5 PT barefoot (Custom-­made force plate
1200 Hz)
Continued

Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918

copyright.
Br J Sports Med: first published as 10.1136/bjsports-2018-099918 on 29 May 2019. Downloaded from http://bjsm.bmj.com/ on August 8, 2020 at Vrije Universiteit Bibliotheek. Protected by
 Review

Br J Sports Med: first published as 10.1136/bjsports-2018-099918 on 29 May 2019. Downloaded from http://bjsm.bmj.com/ on August 8, 2020 at Vrije Universiteit Bibliotheek. Protected by
knee abduction29 38 39 and knee abduction ROM29 38 40 in the

ACLR, ACL reconstructed; Asym, asymmetrical; BK, basketball healthy group; C, controls; D&B, Downs & Black; EF, external focus; EMG, electromyography; F, female; HT, hamstrings tendon graft; allogr, allograft; IF, internal focus; m, months; M, male; NR, not reported; PT,
ACLR leg. Moderate evidence of a small effect was found for

No funding
Source of
higher peak hip adduction angle in landing for ACLR leg39 41

funding
(figures 2 and 3; table 3).

UTD
Yes

Yes

Yes
system Ascension 144 Hz
Electromagnetic tracking
Frontal plane: comparison to healthy controls

Two video cameras JVC

Eight cameras VICON

Eight cameras VICON

8–10 cameras VICON
Pooled data showed strong evidence of a small effect for lower
Data collection

Bertec 1440 Hz knee adduction angles38 41 in ACLR patients at IC and strong

Bertec 1000 Hz

Bertec 1000 Hz
AMTI 2400 Hz
evidence of no difference for the peak knee abduction in
landing.38 39 (figure 2; table 3).
Kinovea

120 Hz

100 Hz

100 Hz
60 Hz

Transverse plane: comparison to contralateral leg

Pooled data showed strong evidence of a small effect for
lower peak knee internal rotation during landing in the ACLR
Max distance

Max distance

Max distance

Max distance

Max distance
leg38 39 and of no difference for the peak hip internal rotation39 41
(figures 2 and 3; table 3).
Test

Transverse plane: comparison to healthy controls

During landing, pooled data showed strong evidence of a
Asym: 164.5±10.9
Height (cm) ±SD

Sym: 166.9±11.2
ACLR: 167.8±6.6

moderate effect for lower peak knee internal rotation in the ACLR
ACLR: 177±4
C: 166.0±5.4

C: 166±9.9

patients38 39 44 (figure 2; table 3).

C: 178±9

177±4
NR

Trunk kinematics
Pooled data showed strong evidence of no difference for trunk
flexion36 39 and moderate evidence of no difference for lateral
Weight (kg) ±SD

Asym: 60.2±16.7

ACLR: 76.8±10.5
Sym: 64.3±11.7
ACLR:66.7±8.9

flexion in landing,36 39 compared with the healthy control group

M: 79.5±10.3

C: 75.8±19.3

76.75±10.53
C: 60.9±6.3

C: 54.4±8.8
F: 67.7±9.9

(figure 3; table 3).

Kinetics

copyright.
Moments: comparison to contralateral leg
Pooled data showed moderate evidence of a moderate effect
Age (years)±SD

ACLR: 28.8±11.2
Asym: 15.6±1.7
ACLR: 18.8±1.7

Sym: 15.6±1.7

for lower knee flexion moments in the reconstructed leg,35 39 42

M: 25.4±7.2
C: 19.2±1.0

C: 14.7±1.5

C: 24.8±9.1
F: 22.8±6.5

28.8±11.2

moderate evidence of a small effect for lower peak hip flexion

moments35 39 42 and limited evidence of a moderate effect for
larger peak ankle dorsiflexion moments35 42 (figure 4A; table 4).
Sample size (male/

Asym: 17 (6M/11F)

Moments: comparison to healthy controls

Sym: 29 (13M/16F)
C: 24 (12M/12F)

Pooled data from three studies26 36 39 showed strong evidence of

M: 30 HT/13 PT/ 65 (45M/20F)

ACLR: 22 (M)
ACLR: 33 (F)

a moderate effect for lower knee flexion moments in the ACLR

C: 22 (M)
female)

C: 31 (F)

22 (M)

group (ES: −0.55, CI −0.87 to −0.22), moderate evidence of

a large effect (ES: 0.97, CI −0.56 to 2.51) for increased peak
knee adduction moments and moderate evidence of no differ-
F: 17 HT/3 PT

ence regarding peak hip flexion moments. Also, pooled data

PT or HT

2 allogr

showed limited evidence of a small effect for higher peak ankle

Graft

dorsiflexion moments26 36 in ACLR patients (figure 4B; table 4).

NR

PT

PT
Time post-­ACLR ±SD

Power absorption: compared with the contralateral leg

Asym: 7.1±1.2 m

Pooled data showed moderate evidence of a strong effect for

Sym: 7.2±1.4 m
31.9±19.4 m

lower power absorption in the reconstructed knee (ES: −0.98,

7.01±0.9 m
M: 6.7±1.0

patella tendon graft; UTD, unable to determine; w, weeks.

F: 6.1±1.1

95% CI −1.37 to −0.60)35 41 and of a small effect for higher

7±0.9 m

absorption in the ankle.35 41 Limited evidence was found that hip

power absorption was similar35 41 (figure 4C; table 4).
D & B Score

GRF: comparison to contralateral leg

(max 19)

Pooled data showed moderate evidence of no difference

16

12

16

16

10

regarding vertical GRF compared with the contralateral leg (ES:

Table 1  Continued

−0.17, CI −0.35 to 0.02)33 35 41 (figure 4D; table 4).

Cross-­sectional

Cross-­sectional

Cross-­sectional

Cross-­sectional

Cross-­sectional
Trigsted et al39

Electromyography
Welling et al40
study design

Xergia et al43

Xergia et al42
Wren et al41

Two studies25 30 investigated the timing of muscle activity onset

Author /

relative to IC in comparison to controls. Pooled data showed

limited evidence of a small effect regarding delayed activation

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6 of 16
Table 2  Studies outcomes and clinical implications
Review

Author Time post-­ACLR Knee scale Activity level LSI (hop distance) Outcomes Clinical implications
25
Bryant et al PT: 15.1±5.0 m CKRS (%) NR NR Successful feed-­forward strategies following ACLR were related to Better functioning individuals used sensory feedback to build treatment-­
HS: 14.2±4.5 m PT: 81.1±16.1 graft selection; HT subjects with superior knee function activated their specific, feed-­forward strategies to compensate for varying levels of
HS: 87.5±11.8 quadriceps earlier and were better able to synchronise peak hamstring mechanical instability, when performing a task known to stress the ACL.
C: 100 muscle activity closer to initial ground contact while more functional PT
subjects demonstrated enhanced tibial control despite a lack of evidence
supporting modified preprogrammed muscular activation patterns.
Button et al26 13.5±9 m 83.3±10.0 CSAS (median) 87% Aiming to identify if different activities challenge ACLR patients DLS and gait should be incorporated early in rehabilitation as loading was
ACLR: 80 differently compared with controls. Knee range of motion was increased comparable but these activities have different roles. DLS permits loading
C: 95 more during squatting, intermediately during hopping, but less during over a larger range of motion, from a stable double stance position and
gait (p<0.01). Peak internal knee extensor moments were highest specifically targets knee extension while gradually increasing squat
during distance hop (p<0.01). The mean value of peak knee moments depth. Gait loads the knee over a small range of motion but potentially
was reduced in squatting and gait (p<0.01) compared with hop. Peak challenges knee control due to the single leg stance. SLHD was the
internal extensor moments were significantly larger during squatting than most challenging activity and ACLR subjects demonstrated reduced
gait and peak external adductor moments during gait compared with performance and biomechanical compensation strategies. Predictably,
squatting (p<0.01). Fluency was highest during squatting (p<0.01). All SLHD should be used in the advanced rehabilitation stage as it challenges
patients demonstrated good recovery of gait but ACL-­deficient subjects knee joint motion, moments and control.
adopted a strategy of increased fluency (p<0.01). During squatting, knee
range of motion and peak internal knee extensor moment were reduced
in all patients (p<0.01). Both patient groups hopped a shorter distance
(p<0.01) and had reduced knee range of motion (p<0.025).
Chen et al27 36±14 m IKDC Tegner 92% Two distinct rotatory landing strategies found at the initial contact period, ITR landing strategy is reported to be the main mechanism for ACL
PT: 92.1±6.1 ACLR: 5.4±0.2 ITR and external tibial rotation. Those adopting ITR strategy exhibited injury. Single-­leg hop test can be used as a screening test for ITR landing
HS: 93.1±5.5 BK: 7±0.0 significantly larger hopping distance and knee strength. Also, they hopped strategy, by observing the extent of toe-­out or knee flexion at the instant
C: 5.2±0.3 faster with straighter knees at foot contact and with larger ITR and less of foot contact during single-­leg hopping. Potentially hop tests can be
knee adduction angular displacement during the initial landing phase. used as predictors of dynamic knee stability.
Proportion of subjects that adopted internal rotation strategy was 20%
for injured leg, 10% for uninjured leg, 34.6% in basketball players and
6.5% in the control group.
Engelen-­van Melick PT-­M: 63.5±23.3 m IKDC Tegner  PT-­M: 98% Similar results were found for quantity of movement (strength Focus on quality of movement as part of ACLR rehabilitation programme
et al28 HS-­M: 41.1±13.5 m PT-­M: 87.7±11.1 PT-­M: 5.7±1.1  HS-­M: 94% measurements) comparing operated and healthy subjects. For quality of and return to sports criteria.
PT-­F: 64.8±25.3 m HS-­M: 86.6±8.7 HS-­M: 5.3±2  PT-­F: 91% movement, only the occurrence of dynamic knee valgus in landing from a
HS-­F: 52.0±20.6 m C-­M: 97.3±4.7 C-­M: 5.2±1.5  HS-­F: 96% jump is higher in operated subjects compared with healthy controls.
PT-­F: 89.2±10.2 PT-­F: 4.9±1.5
HS-­F: 90.4±6 HS-­F: 4.9±1.7
C-­F: 94.9±10.4 C-­F: 4.8±1.2
Gokeler et al30 27±1.5 w 81±7.1 Levels I and II 83.8% In ACL-­reconstructed limbs, significantly earlier onset times were found Asymmetries in muscle activation onset between ACLR and contralateral
athletes for all muscles, except vastus medialis, compared with the uninvolved leg during SLHD. These changes may theoretically predispose to reinjury
side. of the ACL.
Gokeler et al29 IF: 22.6±16.9 w NR Various sports IF: 98.5% Determining the effect of an internal or external attentional focus Demonstrates the applicability of using an external focus during
EF: 28.0±16.7 w EF: 95.2% on jump distance and knee kinematics. The external focus group had rehabilitation of patients after ACLR to enhance safer movement patterns
significantly larger knee flexion angles at initial contact, peak knee compared with an internal focus of attention and subsequently may help
flexion, total ROM, and time to peak knee flexion for the injured leg. to reduce second ACL injury risk.
Hebert-­Losier et al31 20 y NR NR NR Functional data analysis identified specific functional knee-­joint Applying FDA to movements like the one leg hop is feasible and, if
deviations from controls persisting 20 years post-­ACL rupture, especially applied earlier in the rehabilitation process, could guide clinical decision-­
when treated conservatively. This type of analysis has the advantage making by emphasising deficiencies throughout the duration of any task.
of considering the entire time-­varying structure of kinematic data,
identifying relative time intervals in which compromised knee movement
patterns are evident.
Continued

Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918

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 Table 2  Continued
Author Time post-­ACLR Knee scale Activity level LSI (hop distance) Outcomes Clinical implications
32
Letchford et al 6.2±0.6 m NR Tegner NR Using a new motion analysis instrument (2D TIP) to assess landing The 2D TIP instrument has demonstrated appropriate reliability, validity
ACLR: 7.5 (7–10) strategy in ACLR patients, two different landing strategies were defined: and responsiveness for measuring landing strategy in the clinical setting.
C: 5.5 (3–10) a telescopic strategy, which requires increased (internal) knee extensor The instrument is simple, inexpensive and time-­efficient in comparison
moments and is used by healthy subjects; and a pendular strategy which with 3D motion analysis.
requires (internal) flexor moment and is used mostly by ACL-­deficient
patients. Argument made that ACLR patients at 6 months from surgery
and still under rehabilitation therapy, are recovering towards the healthy
strategy.
Moya-­Angeler et al33 3 m NR Physically active >90% Evaluating lower limb kinetics during gait, sprint and hop tests before The isolation of the involved and uninvolved limb seems to be a critical
6m (contact time, hop and after ACLR. The LSI presented high values (90%) at almost all times component in the functional rehabilitation and evaluation before and
12 m time) before and after ACLR in gait, sprint and single leg hop tests (p<0.005), after ACLR, as the uninjured leg may tend to compensate in activities
with a tendency to increase postoperatively. A lower LSI was observed where both limbs are under stress at the same time.
(<90%) in tests where both extremities were tested simultaneously, such
as the drop vertical jump and vertical hop tests (p<0.05).
Nyland et al34 5.2±2.9 y IKDC NR Group 1: 100% Group with better subjective knee function and higher perceived sport Adaptive hip compensations may be related to a permanent neurosensory
Group 1: 91 Group 2: 103% activity intensity had more involved gluteus maximus and medial deficit and CNS sensimotor reorganisation. Rehabilitation should focus
Group 2: 87.2 Group 3: 86% hamstring activation amplitude during propulsion and landing, than the also on CNS re-­education and not only on peripheral neuromuscular
Group 3: 78.6 group with lower subjective knee function. function.
Orishimo et al35 7.2±2.7 m NR NR 93% During propulsion knee motion was significantly reduced compared with Clinicians should be aware that hop ratios based on distance can be
the uninvolved leg (p=0.008). Peak moments and powers were lower at deceiving because equivalent performances are not necessarily indicative
the knee and higher at the ankle and hip (side by joint p=0.011; p=0.003, of similar biomechanics between the involved and uninvolved legs. The
respectively). The peak total extensor moment was not different between compensations by other joints may indicate protective adaptations to
legs (p=0.305) despite a decrease in knee moment and increases in ankle avoid overloading the reconstructed knee.
and hip moments (side by joint p=0.015). During landing, knee motion

Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918

was reduced (p=0.043), and peak power absorbed was decreased at the
knee and hip and increased at the ankle compared with the uninvolved
side (p=0.003).
Roos et al36 7–36 m 86±9.0 Not-­elite sporting NR Hop distance was less for ACLR (p<0.001; ACLR 75.1±17.8; C Parameters other than hopping distance need to be used for the
77.7%±14.07% height). ACLR used a similar kinematic strategy to evaluation of ACLR patients’ recovery such as movement strategies and
healthy control group but had a reduced peak knee flexion moment mediolateral knee control. A telescopic deceleration strategy should be
(p<0.001; ACLR 0.31±0.16; C 0.42±0.13 weight.height). Fluency was promoted.
reduced in ACLR patients (p=0.006; ACLR 0.14±0.34; C 0.17±0.41 s).
Srinivasan et al37 20 y Lysholm Tegner median ACLR: 94% A study with the same ACLR and control group measured in Tengman Coordination variability increased in ACLR compared with controls, no
ACLR: 78±18 ACLR: 4 (3–7) C: 100% et al,38 but with different analysis of the results. Investigating the difference between legs and LSI in distance hopped >90%, indicate a
C: 100 C: 6 (3–7) coordination variability of the hip-­knee joint couplings, they found that poor joint control in ACLR, even 20 years after injury. If estimation of
the ACL group differed significantly from controls on their injured side coordination variability becomes more user-­friendly, this could be a useful
with ~50% higher knee abduction-­adduction/hip internal-­external tool for clinical assessment.
rotation variability during the take-­off phase;~33% higher knee
abduction-­adduction/knee flexion-­extension variability and more knee
abduction-­adduction/hip flexion-­extension variability (ACLR 50%) during
the landing phase. There were no major differences between injured and
non-­injured sides.
Tengman et al38 20 y Lysholm Tegner median ACLR: 94% Kinematic analysis 20 years after ACL injury or reconstruction. Unlike Apart from tibial rotation, ACLR appears to regain a more normalised
ACLR:78±18 ACLR: 4 (3–7) C: 100% controls, ACL-­injured displayed leg asymmetries: less knee flexion and less movement pattern comparable with that of controls, suggesting that
C: 100 C: 6 (3–7) internal rotation at take-­off and landing and more lateral COM related reconstructive surgery may restore the knee biomechanics to some
to knee and ankle joint of the injured leg at landing. Compared with extent. The movement pattern for ACLPT differs in several variables
controls, ACLR had larger external rotation of the injured leg at landing. compared with controls and with the uninjured leg, indicating
The ACL-­injured leg showed less knee flexion and larger external rotation compensatory strategies both regarding knee kinematics as well as the
at take-­off and landing, and larger knee abduction at landing. COM was placement of COM.
more medial in relation to the knee at take-­off and less laterally placed
relative to the ankle at landing.
Continued
Review

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Table 2  Continued
Author Time post-­ACLR Knee scale Activity level LSI (hop distance) Outcomes Clinical implications
Trigsted et al39 31.9±19.4 m IKDC Tegner median 97% Controls demonstrated more peak knee flexion angle, internal knee When evaluating readiness to return to sport, clinicians should use a
ACLR: 88.6±9.4 ACLR: 6 (4–9) extension moment and hip extension moment than ACLR subjects. Within battery of functional tests and note compensations that may be present
C: 95.9±6.1 C: 6 (4–8) the ACLR group, the healthy limb exhibited greater peak knee flexion, hip in the uninjured limb. Clinicians should especially evaluate knee and hip
Recreationally active flexion, hip extension moment, single hop and triple hops distance, and flexion on both limbs to determine whether the patient might be shifting
normalised quadriceps strength. ACLR patients land with their injured demands away from the injured limb towards the healthy side.
leg in a more extended position during an SLHD when compared with a
control group as well as the uninjured leg.
Welling et al40 M: 6.7±1.0 m IKDC NR M: 92.4% Of the patients who passed LSI scores >90% for the SLHD, altered Although LSI scores were >90%, clinically relevant altered movement
F: 6.1±1.1 m M: 81.4±8.3 F: 94.5% movement patterns were present in 60%. No differences were found patterns were detected in the injured leg compared with the uninjured
F: 80.4±8.9 in movement pattern between men and women. Men had a decrease leg. Clinicians should rely not only on LSI scores but also on movement
in knee flexion at IC (p=0.018), peak knee flexion (p=0.002) and knee biomechanics to determine return to sport readiness.
flexion ROM (p=0.017) in the injured leg compared with the uninjured
leg. Women demonstrated a decrease in peak knee flexion (p=0.011)
and knee flexion ROM (p=0.023) in the injured leg compared with the
uninjured leg. Average LSI scores were 92.4% for men and 94.5% for
women.
Wren et al41 Asym: 7.1±1.2 m NR Sport participation Asym: 77% Biomechanical differences between symmetrical and asymmetrical ACLR Hop distance symmetry may not be an adequate test of single limb
Sym: 7.2±1.4 m Sym: 100% patients in terms of LSI. Regardless of hop distance symmetry, patients function and return to sport readiness. During return to sport assessment,
C: 100% offload the ACLR knee 5–12 months after surgery. movement biomechanics should be considered in addition to hop
distance symmetry.
Xergia et al43 7±0.9 m IKDC Tegner median 82.4% Sagittal plane kinematics and isokinetic strength deficits persist 6–9 Suggests a need for more functional interventions to assist ACLR patients
ACLR: 72.4±8.8 Before injury months after ACLR using a PT autograft. Compared with the control to safely return to sports. The ability to attenuate ground reaction forces,
C: 100 ACLR: 7.5 (6–9) group, the ACLR group had greater isokinetic knee extension torque restore symmetrical landing patterns, and increase knee extensor muscle
At testing time deficits at all speeds (p≤0.001) and greater performance asymmetry strength may be facilitated by rehabilitation that emphasises sport-­
ACLR: 5 (4–7) for all three hop tests (p<0.001). Compared with the uninvolved lower specific exercises and neuromuscular training.
C: 8 (7–9) extremity, the injured leg exhibited less ankle dorsiflexion and knee
flexion in the phases of propulsion (p≤0.014) and landing (p≤0.032).
When compared with the control group, the involved lower extremity
exhibited less ankle dorsiflexion in the propulsion phase (p<0.001) but
higher hip flexion in the landing phase (p=0.014).
Xergia et al42 7.01±0.9 m IKDC Tegner median 82% Significant positive correlations between the LSI of the single limb hop Performance on the single limb hop test may be an additional method for
ACLR: 72.4±8.8 Before injury distance and the LSI of the peak extension torque at 120°/s (p=0.044, evaluating muscle strength asymmetries when isokinetic devices are not
ACLR: 7.5 (6–9) r=0.37) and the peak extension torque at 180°/s (p=0.042, r=0.38) as available. However, the single limb hop test cannot be used for evaluating
At testing time well as a negative correlation with the peak flexion torque at 180°/s kinetic and kinematic asymmetries.
ACLR: 5 (4–7) (p=0.043, r = −0.38). LSI of the single limb hop test was not correlated
C: 8 (7–9) with any kinetic or kinematic variable (p>0.05).
ACLR, ACL reconstructed; BK, basketball healthy group; C, controls; CKRS, Cincinnati Knee Rating Scale;CNS, central nervous system; COM, center of mass; CSAS, Cincinnati Sports Activity Scale;DLS, double leg squat; ECC, eccentrics; EF, external focus; F, female;FDA,
functional data analysis; IC, initial contact; IF, internal focus; IKDC, International Knee Documentation Committee;ITR, internal tibial rotation; M, male; NR, not reported;PT, patella tendon graft;ROM, range of motion; TIP, telescopic inverted pendulum; asym.,
asymmetrical; m, months; sym., symmetrical; w, weeks; y, years.

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copyright.
Figure 2  Forest plot for knee kinematics compared with (A) contralateral leg and (B) control group. Studies are ordered according to time since
surgery. ACLR, ACL reconstructed; asym, asymmetrical; EF, external focus; F, female; HS, hamstring tendon graft; IC, initial contact; IF, internal focus; IV,
inverse variance; M, male; m, months; PT, patella tendon graft; ROM, range of motion; Std., standarised; sym, symmetrical; y, years.

of vastus lateralis muscle in ACLR subjects but no difference for
semitendinosus. Also, pooled data showed very limited evidence
of a small effect for delayed activation of vastus medialis and
earlier activation of biceps femoris relative to controls (figure 5;
table 4).
Qualitative synthesis
A number of other biomechanical variables were reported
across all three lower limb joints, all three planes of motion,
during different phases of SLHD. However, most were
reported in a single study and were therefore unable to be
pooled. (online supplementary file 5)
Subgroup analysis
Subgroup analysis according to time since surgery was
performed. The time point was arbitrarily set at 7 months after
surgery when patients after ACLR are often discharged from
care. Pooled data showed strong evidence of a small effect for
decreased peak knee flexion angle during landing both for
ACLR patients up to 7 months after surgery (ES: −0.41, CI

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 Review
Figure 3  Forest plot for hip kinematics compared with contralateral leg (A), ankle kinematics compared with contralateral leg (B) and trunk
kinematics compared with controls (C). Studies are ordered according to time since surgery. ACLR, ACL reconstructed; asym, asymmetrical; IV, inverse
variance; m, months; Std., standardised; sym, symmetrical; ROM, range of motion.
−0.64 to −0.18)29 40 41 43 and more than 7 months (ES: −0.28,
CI −0.54 to −0.02),28 38 39 when compared with the contra-
lateral leg. Interestingly, when compared with controls, there
was no difference (ES: −0.05, CI −0.90 to −0.80)41 found
for patients up to 7 months and a moderate effect (ES: −0.50,
CI −0.73 to −0.28)28 38 39 for those who were more than 7
months after surgery. Similarly, for peak knee abduction angle
in landing comparing with the contralateral leg, no difference
(ES: −0.09, CI −0.78 to 0.60)29 was found for patients up
to 7 months and a moderate effect (ES: −0.39, CI −0.73 to
−0.04)38 39 for those who were more than 7 months after
surgery (online supplementary file 6).
Discussion
This systematic review documented kinematic, kinetic and
EMG deficits at a range of time points postsurgery. A key
finding was that achieving symmetrical SLHD did not ensure
symmetry in kinematic and kinetic variables (figure 6).
While the majority of ACLR patients demonstrated
85%–95% LSI for distance during SLHD test, there are a range
of biomechanical deficits in most of the outcomes compared
with the contralateral leg. From a clinical perspective, given
the high rate of reinjury and contralateral ACL rupture (19%
and 22%, respectively, in young athletes)3 and the low rate of
athletes returning to their previous level of activity (67%),2
these individual differences warrant further investigation.
Kinematic and kinetic differences are more likely to give us
useful information than the simplistic aggregate ‘distance
hopped’.
Kinematics
Lower limb biomechanics of ACLR patients differed from
both the contralateral leg and the control group. Specifically,
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during landing the reconstructed limb had less peak knee
flexion, internal rotation and knee flexion ROM (4.2°, 3.4°
and 3.9°, respectively) when compared with the contralateral
leg, with larger effect size (ES) and absolute values for peak
knee internal rotation and knee flexion ROM when compared
with controls. The ACLR limb landed with less peak knee
abduction compared with the uninjured leg, but no difference
was found compared with controls.
Two studies used biplane fluoroscopy to record 6 df tibiofem-
oral joint kinematics during single leg hop landing (although
not max hop for distance) in people with unilateral ACLR.45 46
Biplanar fluoroscopy is the current gold standard for recording
joint kinematics during dynamic functional activities. Interest-
ingly, both studies demonstrate reduced knee flexion and less
internal rotation for the ACLR limb relative to the unaffected
limb, but no difference between limbs in knee abduction/
adduction. These findings are largely consistent with results
for knee frontal and transverse plane motions reported in the
current review. We report no differences in trunk kinematics.
We speculate that the decreased knee flexion angles may be due
to altered quadriceps activation, which is selectively affected at
45° of knee flexion47 or decreased quadriceps strength,43 which
could result in landing with a more upright position.45
From a clinical prospective, a ‘stiff ’ landing strategy in
ACLR patients, with less knee ROM during landing, can result
in larger stress on the ACL. Patients should be trained to use
‘soft’ landings.48 Subgroup analysis revealed that some kine-
matic variables (peak knee flexion and peak knee adduction)
do not seem to return to ‘normal’, and may even deteriorate
with time. It should be noted that the differences reported,
while statistically significant, are relatively small, and likely
not detectable with the naked eye. Further, for these measures
the minimum clinically important difference is not known.
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918

Figure 4  Forest plot for peak lower limb moments in landing compared with (A) contralateral leg and (B) control group, power absorption in
landing (C) and ground reaction force in landing (D) compared with contralateral leg. Studies are ordered according to time since surgery. ACLR, ACL
reconstructed; GRF, ground reaction force; IV, inverse variance; m, months; Std., standardised.
Figure 5  Forest plot for timing of muscle activity onset relative
to initial contact compared with control group. studies are ordered
according to time since surgery. ACLR, ACL reconstructed; HS,
hamstrings tendon graft; IV, inverse variance; m, months; PT, patella
tendon graft; Std., standardised.
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918
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copyright.
Kinetics
Patients with ACLR produce lower knee and hip flexion
moments when landing. Compared with healthy individuals,
ACLR patients land with greater knee adduction moments.
Pooled results showed moderate evidence of no difference in the
magnitude of GRF. Since moments were different (comparing
ACLR to the uninjured leg and the control group), we speculate
that moment arms were larger in the ACLR patients. Oberländer
et al49 reported that the ACLR leg landed with a more flexed
trunk compared with the uninvolved leg. By flexing their trunk,
the GRF vector was shifted anteriorly in relation to the knee,
ankle and hip joint axis, leading to a shift of the joint moment
output from the knee to the adjacent joints. Pooled data in our
review, however, showed strong evidence of no difference in
trunk kinematics during landing.
Wren et al41 classified their cohort of ACLR subjects as
symmetrical or asymmetrical according to LSI during SLHD.
During landing, the operated limb, regardless of hop distance,
exhibited lower knee flexion moments compared with controls
and the contralateral side with lower knee energy absorption
than the contralateral side. Both symmetrical and asymmetrical
patients offloaded the operative knee; symmetrical patients
achieved symmetry, in part, by hopping a shorter distance on the
contralateral side.
Letchford et al,32 using a telescopic inverted pendulum model,
defined two different landing strategies: (1) The ‘telescopic’,
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Table 3  Summary of evidence—kinematics

Joint Variable Comparison SMD (95% CI) MD (95% CI) Level of evidence Clinical significance
Knee Peak flexion in propulsion Contralateral −0.38 (-0.69 to -0.07) −3.6° (−6.8° to −0.5°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
    Control −0.28 (-0.58 to 0.02) −2.4° (−5.0° to 0.2°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in ACLR patients compared with controls.
  ROM flexion in propulsion Contralateral −0.46 (-0.77 to -0.16) −5.0° (−8.9° to −1.1°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
    Control −0.33 (-0.63 to -0.02) −2.9° (−5.8° to 0.0°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in ACLR patients compared with controls.
  Flexion at IC Contralateral −0.11 (-0.33 to 0.11) −0.8° (−2.2° to 0.5°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with contralateral.
    Control −0.03 (-0.32 to 0.25)  0.0° (−1.8° to 1.7°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with controls.
  Adduction at IC Contralateral 0.04 (-0.26 to 0.32) −0.1° (−1.2° to 1.1°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with contralateral.
    Control −0.46 (-1.15 to 0.24) −1.4° (−3.5° to 0.7°) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for lower angles in ACLR patients compared with controls.
  Peak flexion in landing contralateral −0.36 (-0.52 to -0.18) −4.2° (−6.1° to −2.2°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
    Control −0.37 (-0.64 to -0.10) −4.4° (−7.7° to −1.0°) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for lower angles in ACLR patients compared with controls.
  Peak abduction in landing Contralateral −0.33 (-0.64 to -0.02) −2.4° (−4.3° to −0.4°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
    Control −0.12 (-0.46 to 0.23) −1.0° (−3.2° to 1.3°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with controls.
  Peak internal rotation in landing Contralateral −0.41 (-0.89 to 0.07) −3.4° (−6.0° to −0.9°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
    Control −0.51 (-0.86 to -0.16) −4.6° (−6.3° to −2.9°) ⊕⊕⊕⊕⊕ Strong level of evidence of a moderate effect for lower angles in ACLR patients compared with controls.
  ROM flexion in landing Contralateral −0.43 (-0.67 to -0.18) −3.9° (−6.1° to −1.6°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
    Control −0.48 (-0.81 to -0.16) −5.4° (−9.1° to −1.7°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with controls.
  ROM abduction in landing Contralateral −0.22 (-0.49 to 0.04) −0.2° (−0.7° to 0.2°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
           
Hip Peak flexion in propulsion Contralateral −0.16 (-0.52 to 0.19) −2.4° (−7.3° to 2.6°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with contralateral.
  ROM flexion in propulsion contralateral −0.47 (-1.14 to 0.21) −7.0° (−16.9° to 2.9°) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for lower angles in injured leg compared with contralateral.
  Peak flexion in landing Contralateral −0.10 (-0.46 to 0.24) −1.7° (−7.4° to 4°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
  Peak adduction in landing Contralateral 0.22 (-0.32 to 0.76) 1.5° (−2.2° to 5.2°) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for higher angles in injured leg compared with contralateral.
  Peak internal rotation in landing Contralateral 0.07 (-0.26 to 0.41) 1.1° (−1.2° to 3.5°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with contralateral.
           
Ankle Peak dorsiflexion in propulsion Contralateral −0.28 (-0.81 to 0.25) −1.9° (−5.4° to 1.6°) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for lower angles in injured leg compared with contralateral.
  ROM dorsiflexion in propulsion Contralateral −0.37 (-0.76 to 0.02) −3.9° (−7.6° to −0.2°) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for lower angles in injured leg compared with contralateral.
  Peak dorsiflexion in landing Contralateral −0.26 (-0.60 to 0.07) −2.0° (−4.8° to 0.8°) ⊕⊕⊕⊕⊕ Strong level of evidence of a small effect for lower angles in injured leg compared with contralateral.
           
Trunk Flexion in landing Control 0.13 (-0.26 to 0.51) 0.8° (−3.1° to 4.7°) ⊕⊕⊕⊕⊕ Strong level of evidence of no difference in injured leg compared with controls
  Lateral flexion in landing Control −0.05 (-0.68 to 0.58) −0.2° (−3.4° to 3.0°) ⊕⊕⊕⊕ Moderate level of evidence of no difference in injured leg compared with controls

ACLR, ACL reconstructed; IC, initial contact; MD, mean difference; ROM, range of motion;SMD, standardised mean difference.
Note: ⊕⊕⊕⊕⊕ indicates strong level of evidence; ⊕⊕⊕⊕ indicates moderate level of evidence.

Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918

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Table 4  Summary of evidence—kinetics
Measurement Variable Comparison SMD (95% CI) Level of evidence Clinical significance
Moments Peak knee flexion Contralateral −0.76 (-1.73 to 0.23) ⊕⊕⊕⊕ Moderate level of evidence of a moderate effect for lower
moment moments in injured leg compared with contralateral.
  Peak knee flexion Control −0.55 (-0.87 to -0.22) ⊕⊕⊕⊕⊕ Strong level of evidence of a moderate effect for lower
moment moments in injured leg compared with controls.
  Peak knee adduction Control 0.97 (−0.56 to 2.51) ⊕⊕⊕⊕ Moderate level of evidence of a strong effect for increased
moment moments in injured leg compared with controls.
  Peak hip flexion moment Contralateral −0.28 (−0.62 to 0.06) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for lower
moments in injured leg compared with contralateral.
  Peak hip flexion moment Control 0.03 (−0.62 to 0.68) ⊕⊕⊕⊕ Moderate level of evidence of no difference in injured leg
compared with controls.
  Peak ankle dorsiflexion Contralateral 0.46 (−0.02 to 0.94) ⊕⊕⊕ Limited level of evidence of a small effect for increased
moment moments in injured leg compared with contralateral.
  Peak ankle dorsiflexion Control 0.26 (−0.18 to 0.68) ⊕⊕⊕ Limited level of evidence of a small effect for increased
moment moments in injured leg compared with controls.
GRF Vertical ground reaction Contralateral −0.17 (−0.35 to 0.02) ⊕⊕⊕⊕ Moderate level of evidence of no difference in injured leg
force compared with contralateral.
EMG timing of onset Vastus medialis Control 0.21 (−0.54 to 0.95) ⊕⊕ Very limited level of evidence of a small effect for delayed
muscle activity relative muscle activation onset in injured leg compared with
to IC controls.
  Vastus lateralis Control 0.36 (−0.07 to 0.78) ⊕⊕⊕ Limited level of evidence of a small effect for delayed
muscle activation onset in injured leg compared with
controls.
  Semitendinosus Control −0.11 (−0.71 to 0.49) ⊕⊕⊕ Limited level of evidence of no difference in muscle
activation onset in injured leg compared with controls.
  Biceps femoris Control −0.27 (−1.04 to 0.50) ⊕⊕ Very limited level of evidence of a small effect for early
muscle activation onset in injured leg compared with
controls.
         
Power absorption Hip in landing Contralateral −0.15 (−0.69 to 0.38) ⊕⊕⊕ Limited level of evidence of a small effect for decreased
power absorption in injured leg compared with
contralateral.

copyright.
  Knee in landing Contralateral −0.98 (−1.37 to -0.60) ⊕⊕⊕⊕ Moderate level of evidence of a strong effect for
decreased power absorption in injured leg compared with
contralateral.
  Ankle in landing Contralateral 0.21 (−0.15 to 0.58) ⊕⊕⊕⊕ Moderate level of evidence of a small effect for
increased power absorption in injured leg compared with
contralateral.
Note: ⊕⊕⊕⊕⊕ indicates strong level of evidence; ⊕⊕⊕⊕ indicates moderate level of evidence, ⊕⊕⊕ indicates limited level of evidence, ⊕⊕ indicates very limited level of evidence.
EMG, electromyography; GRF, ground reaction force;IC, initial contact; SMD, standardised mean difference.

which requires greater knee flexion moments, and was used by
healthy subjects. (2) The ‘pendular’, which required extension
moments and was used mostly by ACL-­deficient patients. The
authors argued that ACLR patients at 6 months after surgery and
still under rehabilitation, were recovering towards the strategy
of healthy individuals.
The present data suggest that restoring symmetry in hop
distance does not ensure that knee kinematics and kinetics are
restored after ACLR. It is suggested that at least in addition to
hop distance, kinematics and kinetics should be considered as
RTP criteria. Preliminary, but clinically relevant, evidence from
a recent case study50 assessing biomechanical parameters during
an SLHD test before ACL injury and 27 months after reconstruc-
tion support this approach of examining subject-­specific differ-
ences incurred as a result of ACL injury, rather than relying on
group means.
Electromyography
There is not enough evidence to draw strong conclusions
regarding muscle activity patterns in ACLR patients during
SLHD. The two studies available are too heterogenous—
partially due to the difference in time since surgery: Gokeler et
al30 assessed the patients at 6 months after surgery, while Bryant
et al25 evaluated them 1 year after surgery. Likely, muscle acti-
vation patterns and strategies following ACLR change with time
and influenced by postoperative pain, arthrogenic muscle inhibi-
tion, fear of movement and other factors.51 52
While the evidence is limited regarding alteration in muscle
activation, some preliminary observations can be made regarding
knee and hip muscle activation differences and possible mech-
anisms. It has been suggested that the importance of early
hamstring activation prior to impact is diminished when ante-
rior knee stability is restored.25 However, this finding confirms
the notion that neuropathways other than those mediated by
mechanoreceptors within the normal ACL must exist and coor-
dinate hamstring muscle activity.53 On the other hand, perceived
higher-­level sports capability compared with preknee-­ injury
status was associated with increased lower extremity neuromus-
cular compensations through hip muscle groups such as gluteus
maximus and medial hamstrings.34 Gluteus maximus plays
a significant role in frontal plane motion at the hip and may
limit excessive dynamic knee valgus.54 Nevertheless, greater fear
of reinjury is associated with greater quadriceps preactivation
leading to stiffened movement patterns and potential risk factors
of secondary ACL injury.52 Since ACL reconstruction restores
mechanical, but not necessarily neurosensory function,55 reha-
bilitation could focus more on central nervous system re-­ed-
ucation rather than solely attempting to optimise peripheral
neuromuscular function.34

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copyright.
Figure 6  Sagittal and frontal view during different phases of single leg hop for distance of an ACLR patient. Pooled data only presented where
there is evidence from the meta-­analysis of either: strong evidence of a strong or moderate effect, or moderate evidence of a large effect. No data
are presented for small or trivial effects, or weak evidence. angles are reported as the range of the mean difference. Kinetics are reported as effect
sizes. Values are reported as the difference of the reconstructed leg (coloured lower limb) compared with the contralateral healthy leg (values in red)
or compared with controls (values in blue, italics). Negative values indicate lower values for the reconstructed leg. ACLR, ACL reconstructed; ES, effect
size; ROM, range of motion; ABD, abduction; IR, internal rotation.

Assessment of methodological quality and level of evidence
The methodological quality of included studies was relatively
adequate with the majority presenting MQ to HQ. Four quality
domains were the most frequent sources of methodological
considerations and bias: blinding of outcome assessors, lack of
adjustment for confounders, lack of power analysis and sample
size calculation, and selection bias resulting from the lack of
description of source of patient population. Pooled data for
kinematics showed high and moderate levels of evidence, while
regarding kinetics the levels of evidence were more variable.
However, the level of evidence was judged as low for a notable
number of kinetics, kinematics and EMG data retrieved from
single studies.
Limitations
While the levels of evidence provide a synthesis of the quality,
quantity and homogeneity of study results, all relevant studies,
regardless of methodological quality, were included. Therefore,
we acknowledge the potential bias through the inclusion of poor
quality and/or biassed studies. Also, a funnel plot for assessment
of publication bias was not created due to the small number
of included studies for each dependent variable. Moreover,
there are not enough data available to subgroup our findings
according to graft type used. This review was registered (PROS-
PERO reg no: CRD42018087779) and conducted examining all
hop tests in ACLR patients. In this paper we have only reported
the results of SLHD. The research in this area includes: hop for
maximal distance, submaximal hop for distance (eg, hopping
50% of limb length), hopping over obstacles, triple hop, side
hop and drop jump testing. The current review has included only
the results of SLHD in part because of our perception regarding
clinical applicability, and in part because of word count limits for
the journal. Future research can report these alternate hop test
results in a similar manner. Data for knee joint kinematics have
been obtained from skin-­mounted motion capture systems that
are affected by soft tissue artefact (skin/muscle movement with
respect to underlying bone) especially during high-­impact tasks.
This issue limits the ability of skin-­ mounted motion capture
systems to accurately track small secondary joint motions such as
knee varus/valgus and axial rotation. Moreover, five studies used
two-­dimensional equipment for data collection.28–30 32 40 Three
of these studies28 29 40 reported knee flexion and adduction angles

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and were included in the meta-­analysis, although sensitivity anal-
ysis appeared to show that these studies didn't influence the main
results from our systematic review (online supplementary file 7).
The differences in muscle activation patterns have not been as
deeply analysed as have those for kinematics and kinetics there-
fore we are unable to adequately inform practitioners regarding
appropriate muscle activation strategies. Importantly it remains
to be seen if normalisation of these movement patterns is associ-
ated with enhanced clinical outcomes. The requirement of rela-
tively expensive equipment, and time and expertise to conduct
such analyses, remain a significant barrier to overcome for most
clinicians, especially given the current lack of evidence of effi-
cacy or effectiveness for any interventions addressing these
biomechanical differences.
Clinical implications and future research
Deficits in kinematics and kinetics were detected in patients after
ACLR during SLHD. It seems from first principles that it would
be wise for clinicians and patients to consider correcting these
deficits before RTP. Note that we have no prospective data to
suggest this will lower the rate of recurrence of ACL injury or
contralateral injury.
These deficits should be analysed and addressed within
rehabilitation. Detecting and correcting altered landing strat-
egies should be part of a more individualised rehabilitation
programme. Further research is needed to draw strong conclu-
sions on the biomechanical adaptations after ACLR during
a range of functional tests to establish if these differences are
time-­dependent and if asymmetries are associated with clinical
outcomes—specifically does restoration of knee function result
in lower reinjury rates.
Whether different surgical approaches (eg, hamstring auto-
graft vs patellar tendon, lateral tenodesis, etc) influence the
elements we have described in this study, is outside our scope.
These investigations would require longitudinal study designs.
We suggest that reporting only discrete distance values does
not adequately characterise the quality of movement. Muscle
activation patterns have not been examined in any great depth.
Since relatively large cohorts will be required, and ACL injury is
relatively rare, standardised reporting is recommended to allow
pooling of data.
Comparing with the uninjured leg differed from comparing
with healthy controls. Examining the ES of differences, where
What is already known?
►► The rate of reinjury after ACL reconstructed (ACLR) is high.
►► Failure to achieve some simple functional tests are associated
with elevated risk of reinjury.
What are the new findings?
►► A symmetrical SLHD test does not indicate restoration of
normal lower-­limb kinematics or kinetics.
►► ACLR patients tend to offload their reconstructed knee,
landing with less knee flexion, less knee flexion moments and
less knee energy absorption (‘stiff landing’ strategy).
►► Achieving >90% hop distance for the ACLR leg compared
with the uninjured leg is usually associated with
compensatory movements at the hip, ankle and/or knee
joints.
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918
Review
Br J Sports Med: first published as 10.1136/bjsports-2018-099918 on 29 May 2019. Downloaded from http://bjsm.bmj.com/ on August 8, 2020 at Vrije Universiteit Bibliotheek. Protected by
possible, the largest difference was noted in knee moment (−0.8
cf −0.6) with relatively minor differences in kinematics, and not
enough information for EMG. Therefore, we suggest that a key
component of future research is inclusion of knee moment esti-
mation. Unfortunately for the practicing clinician, this currently
requires specialised equipment and analyses.
Conclusion
During SLHD several kinematic and kinetic deficits were
detected between limbs after ACLR, despite adequate SLHD
performance. Measuring only hop distance, even using the
healthy leg as a reference, is insufficient to fully assess knee func-
tion after ACLR.
Acknowledgements  The authors thank the reviewers for assistance, especially
Prof Roald Bahr for helpful comments and suggestions which have improved the
paper.
Contributors  All authors contributed significantly to the review. AK conducted the
entire review, with VK and RW as second and third reviewers. SVR and IJ provided
advice throughout the review. All authors contributed to the final manuscript.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
ORCID iD
Argyro Kotsifaki http://​orcid.​org/​0000-​0002-​7902-​9206
References
1 Bahr R, Clarsen B, Ekstrand J. Why we should focus on the burden of injuries and
illnesses, not just their incidence. Br J Sports Med 2018;52:1018–21.
copyright.
2 Ardern CL, Webster KE, Taylor NF, et al. Return to the preinjury level of competitive
sport after anterior cruciate ligament reconstruction surgery: two-­thirds of patients
have not returned by 12 months after surgery. Am J Sports Med 2011;39:538–43.
3 Wiggins AJ, Grandhi RK, Schneider DK, et al. Risk of secondary injury in younger
athletes after anterior cruciate ligament reconstruction: a systematic review and
meta-­analysis. Am J Sports Med 2016;44:1861–76.
4 Goerger BM, Marshall SW, Beutler AI, et al. Anterior cruciate ligament injury alters
preinjury lower extremity biomechanics in the injured and uninjured leg: the JUMP-­
ACL study. Br J Sports Med 2015;49:188–95.
5 Leppänen M, Pasanen K, Kujala UM, et al. Stiff Landings are associated with
increased ACL injury risk in young female Basketball and Floorball players. Am J
Sports Med 2017;45:386–93.
6 Paterno MV. Incidence and predictors of second anterior cruciate ligament injury after
primary reconstruction and return to sport. J Athl Train 2015;50:1097–9.
7 Abrams GD, Harris JD, Gupta AK, et al. Functional performance testing after anterior
cruciate ligament reconstruction. Orthop J Sports Med 2014;2.
8 van Melick N, van Cingel REH, Brooijmans F, et al. Evidence-­based clinical
practice update: practice guidelines for anterior cruciate ligament rehabilitation
based on a systematic review and multidisciplinary consensus. Br J Sports Med
2016;50:1506–15.
9 Kyritsis P, Bahr R, Landreau P, et al. 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 2016;50:946–51.
10 Gokeler A, Welling W, Benjaminse A, et al. A critical analysis of limb symmetry indices
of hop tests in athletes after anterior cruciate ligament reconstruction: a case control
study. Orthop Traumatol Surg Res 2017;103:947–51.
11 Wellsandt E, Failla MJ, Snyder-­Mackler L. Limb symmetry indexes can overestimate
knee function after anterior cruciate ligament injury. J Orthop Sports Phys Ther
2017;47:334–8.
12 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews
and meta-­analyses: the PRISMA statement. BMJ 2009;339:b2535.
13 Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. John
Wiley & Sons, 2011.
14 Lin J, Wilbur WJ. PubMed related articles: a probabilistic topic-­based model for
content similarity. BMC Bioinformatics 2007;8.
15 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the
methodological quality both of randomised and non-­randomised studies of health
care interventions. J Epidemiol Community Health 1998;52:377–84.
16 Mosler AB, Agricola R, Weir A, et al. Which factors differentiate athletes with hip/groin
pain from those without? A systematic review with meta-­analysis. Br J Sports Med
2015;49.
15 of 16
 Review
17 Munn J, Sullivan SJ, Schneiders AG. Evidence of sensorimotor deficits in functional
ankle instability: a systematic review with meta-­analysis. J Sci Med Sport
2010;13:2–12.
18 Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale:
Erlbaum, 1988.
19 Higgins JPT, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-­analyses.
BMJ 2003;327:557–60.
20 Normand SL. Meta-­analysis: Formulating, evaluating, combining, and reporting. Stat
Med 1999;18:321–59.
21 Schriger DL, Altman DG, Vetter JA, et al. Forest plots in reports of systematic reviews:
a cross-­sectional study reviewing current practice. Int J Epidemiol 2010;39:421–9.
22 van Tulder M, Furlan A, Bombardier C, et al. Updated method guidelines for systematic
reviews in the Cochrane collaboration back review group. Spine 2003;28:1290–9.
23 Hart HF, Culvenor AG, Collins NJ, et al. Knee kinematics and joint moments during gait
following anterior cruciate ligament reconstruction: a systematic review and meta-­
analysis. Br J Sports Med 2016;50:597–612.
24 King MG, Lawrenson PR, Semciw AI, et al. Lower limb biomechanics in
femoroacetabular impingement syndrome: a systematic review and meta-­analysis. Br J
Sports Med 2018;52:566–80.
25 Bryant AL, Newton RU, Steele J. Successful feed-­forward strategies following ACL
injury and reconstruction. J Electromyogr Kinesiol 2009;19:988–97.
26 Button K, Roos PE, van Deursen RWM. Activity progression for anterior cruciate
ligament injured individuals. Clin Biomech 2014;29:206–12.
27 Chen W-­L, Chen Y-T­ , Huang S-­Y, et al. Landing strategies focusing on the control of
tibial rotation in the initial contact period of one-­leg forward hops. Scand J Med Sci
Sports 2017;27:832–41.
28 Engelen-­van Melick N, van Cingel REH, van Tienen TG, et al. Functional performance
2–9 years after ACL reconstruction: cross-­sectional comparison between athletes with
bone–patellar tendon–bone, semitendinosus/gracilis and healthy controls. Knee Surg
Sports Traumatol Arthrosc 2017;25:1412–23.
29 Gokeler A, Benjaminse A, Welling W, et al. The effects of attentional focus on jump
performance and knee joint kinematics in patients after ACL reconstruction. Phys Ther
Sport 2015;16:114–20.
30 Gokeler A, Hof AL, Arnold MP, et al. Abnormal landing strategies after ACL
reconstruction. Scand J Med Sci Sports 2010;20:e12–19.
31 Hébert-­Losier K, Pini A, Vantini S, et al. One-­leg hop kinematics 20years following
anterior cruciate ligament rupture: data revisited using functional data analysis. Clin
Biomech 2015;30:1153–61.
32 Letchford R, Button K, Adamson P, et al. A novel clinical approach for assessing hop
landing strategies: a 2D telescopic inverted pendulum (tip) model. Knee Surg Sports
Traumatol Arthrosc 2016;24:279–86.
33 Moya-­Angeler J, Vaquero J, Forriol F. Evaluation of lower limb kinetics during gait,
sprint and hop tests before and after anterior cruciate ligament reconstruction. J
Orthop Traumatol 2017;18:177–84.
34 Nyland J, Wera J, Klein S, et al. Lower extremity neuromuscular compensations during
instrumented single leg hop testing 2-10 years following ACL reconstruction. Knee
2014;21:1191–7.
35 Orishimo KF, Kremenic IJ, Mullaney MJ, et al. Adaptations in single-­leg hop
biomechanics following anterior cruciate ligament reconstruction. Knee Surg Sports
Traumatol Arthrosc 2010;18:1587–93.
36 Roos PE, Button K, Sparkes V, et al. Altered biomechanical strategies and medio-­lateral
control of the knee represent incomplete recovery of individuals with injury during
single leg hop. J Biomech 2014;47:675–80.
16 of 16
Br J Sports Med: first published as 10.1136/bjsports-2018-099918 on 29 May 2019. Downloaded from http://bjsm.bmj.com/ on August 8, 2020 at Vrije Universiteit Bibliotheek. Protected by
37 Srinivasan D, Tengman E, Häger CK. Increased movement variability in one-­leg hops
about 20 years after treatment of anterior cruciate ligament injury. Clin Biomech
2018;53:37–45.
38 Tengman E, Grip H, Stensdotter A, et al. Anterior cruciate ligament injury about 20
years post-­treatment: a kinematic analysis of one-­leg hop. Scand J Med Sci Sports
2015;25:818–27.
39 Trigsted SM, Post EG, Bell DR. Landing mechanics during single hop for distance in
females following anterior cruciate ligament reconstruction compared to healthy
controls. Knee Surg Sports Traumatol Arthrosc 2017;25:1395–402.
40 Welling W, Benjaminse A, Seil R, et al. Altered movement during single leg hop test
after ACL reconstruction: implications to incorporate 2-­D video movement analysis for
hop tests. Knee Surg Sports Traumatol Arthrosc 2018;26:3012–9.
41 Wren TAL, Mueske NM, Brophy CH, et al. Hop distance symmetry does not indicate
normal landing biomechanics in adolescent athletes with recent anterior cruciate
ligament reconstruction. J Orthop Sports Phys Ther 2018;48:622–9.
42 Xergia SA, Pappas E, Georgoulis AD. Association of the single-­limb hop test with
isokinetic, kinematic, and kinetic asymmetries in patients after anterior cruciate
ligament reconstruction. Sports Health 2015;7:217–23.
43 Xergia SA, Pappas E, Zampeli F, et al. Asymmetries in functional hop tests, lower
extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior
cruciate ligament reconstruction. J Orthop Sports Phys Ther 2013;43:154–62.
44 Webster KE, Feller JA. Tibial rotation in anterior cruciate ligament reconstructed knees
during single limb hop and drop landings. Clin Biomech 2012;27:475–9.
45 Deneweth JM, Bey MJ, McLean SG, et al. Tibiofemoral joint kinematics of the anterior
cruciate ligament-­reconstructed knee during a single-­legged hop landing. Am J Sports
Med 2010;38:1820–8.
46 Hofbauer M, Thorhauer ED, Abebe E, et al. Altered tibiofemoral kinematics in the
affected knee and compensatory changes in the contralateral knee after anterior
cruciate ligament reconstruction. Am J Sports Med 2014;42:2715–21.
47 Krishnan C, Theuerkauf P. Effect of knee angle on quadriceps strength and activation
after anterior cruciate ligament reconstruction. J Appl Physiol 2015;119:223–31.
48 Laughlin WA, Weinhandl JT, Kernozek TW, et al. The effects of single-­leg landing
technique on ACL loading. J Biomech 2011;44:1845–51.
49 Oberländer KD, Brüggemann G-­P, Höher J, et al. Altered landing mechanics in ACL-­
reconstructed patients. Med Sci Sports Exerc 2013;45:506–13.
50 Samaan MA, Ringleb SI, Bawab SY, et al. Altered lower extremity joint mechanics
occur during the StAR excursion balance test and single leg hop after ACL-­
copyright.
reconstruction in a collegiate athlete. Comput Methods Biomech Biomed Engin
2018;21:344–58.
51 Hart JM, Pietrosimone B, Hertel J, et al. Quadriceps activation following knee
injuries: a systematic review. J Athl Train 2010;45:87–97.
52 Trigsted SM, Cook DB, Pickett KA, et al. Greater fear of reinjury is related to
stiffened jump-­landing biomechanics and muscle activation in women after ACL
reconstruction. Knee Surg Sports Traumatol Arthrosc 2018;26:3682–9.
53 Ciccotti MG, Kerlan RK, Perry J, et al. An electromyographic analysis of the
knee during functional activities. II. the anterior cruciate ligament-­deficient and
-reconstructed profiles. Am J Sports Med 1994;22:651–8.
54 Hollman JH, Galardi CM, Lin I-­H, et al. Frontal and transverse plane hip kinematics
and gluteus maximus recruitment correlate with frontal plane knee kinematics
during single-­leg squat tests in women. Clin Biomech 2014;29:468–74.
55 Valeriani M, Restuccia D, Di Lazzaro V, et al. Clinical and neurophysiological
abnormalities before and after reconstruction of the anterior cruciate ligament of
the knee. Acta Neurol Scand 1999;99:303–7.
Kotsifaki A, et al. Br J Sports Med 2020;54:139–153. doi:10.1136/bjsports-2018-099918