Journal of Sport Rehabilitation, 2013, 22, 150-156

2013 Human Kinetics, Inc.

www.JSR-Journal.com
CRITICALLY APPRAISED TOPIC

Effect of Eccentric Strengthening After Anterior Cruciate

Ligament Reconstruction on Quadriceps Strength
Lindsey K. Lepley and Riann M. Palmieri-Smith
Clinical Scenario: Interventions aimed at safely overloading the quadriceps muscle after anterior cruciate ligament (ACL) reconstruction are essential to reducing quadriceps muscle weakness that often persists long after
the rehabilitation period. Despite the best efforts of clinicians and researchers to improve ACL rehabilitation
techniques, a universally effective intervention to restore preinjury quadriceps strength has yet to be identified.
A muscles force-producing capacity is most optimal when an external force exceeds that of the muscle while
the muscle lengthens. Hence, the potential to improve muscle strength by overloading the tissue is greater with
eccentric strengthening than with concentric strengthening. Traditionally, the application of early postoperative
high-intensity eccentric resistance training to the ACL-reconstructed limb has been contraindicated, as there is
potential for injury to the ACL graft, articular cartilage, or surrounding soft-tissue structures. However, recent
evidence suggests that the application of early, progressive, high-force eccentric resistance exercises to the
involved limb can be used to safely increase muscle volume and strength in ACL-reconstructed individuals.
As a result, eccentric strengthening may be another attractive alternative to traditional concentric strengthening to improve quadriceps strength after ACL reconstruction. Focused Clinical Question: In patients who
have undergone ACL reconstruction, is there evidence to suggest that eccentric exercise positively affects
postoperative quadriceps strength?
Keywords: knee, postoperative quadriceps strength, negative resistance

Clinical Scenario
Interventions aimed at safely overloading the quadriceps
muscle after anterior cruciate ligament (ACL) reconstruction are essential to reducing quadriceps muscle
weakness that often persists long after the rehabilitation period. Despite the best efforts of clinicians and
researchers to improve ACL rehabilitation techniques,
a universally effective intervention to restore preinjury
quadriceps strength has yet to be identified. A muscles
force-producing capacity is most optimal when an
external force exceeds that of the muscle while the
muscle lengthens.1,2 Hence, the potential to improve
muscle strength by overloading the tissue is greater with
eccentric strengthening than with concentric strengthening. Traditionally, the application of early postoperative
high-intensity eccentric resistance training to the ACLreconstructed limb has been contraindicated, as there
is potential for injury to the ACL graft, articular cartilage, or surrounding soft-tissue structures.3 However,
recent evidence suggests that the application of early,
progressive, high-force eccentric resistance exercises
to the involved limb can be used to safely increase

The authors are with the School of Kinesiology, University of

Michigan, Ann Arbor, MI.

150

muscle volume and strength in ACL-reconstructed

individuals.4,5 As a result, eccentric strengthening may
be another attractive alternative to traditional concentric
strengthening to improve quadriceps strength after ACL
reconstruction.

Focused Clinical Question

In patients who have undergone ACL reconstruction, is
there evidence to suggest that eccentric exercise positively
affects postoperative quadriceps strength?

Summary of Search,
Best Evidence Appraised,
and Key Finding
The literature was searched for studies of level 3
evidence or higher that investigated the effect of
an eccentric-exercise intervention on quadriceps
strength in ACL-reconstructed participants.
Two high-quality randomized control trials5,6 and 2
cohort studies were included.7,8
All 4 studies58 supported the use of eccentric
strengthening to improve quadriceps strength after
ACL reconstruction.

Eccentric Strengthening After ACL Reconstruction 151

Clinical Bottom Line

Exclusion Criterion
Studies that did not report isometric or isokinetic
quadriceps strength in response to an eccentricexercise intervention

There is strong evidence to suggest that the use of eccentric exercises after ACL reconstruction positively affects
postoperative quadriceps strength. Compared with concentric exercise, eccentric exercise on the involved limb
may result in greater quadriceps strength immediately
after ACL reconstruction5 and up to 1 year postsurgery.6
Strength of Recommendation: Based on the Centre
for Evidence-Based Medicine, there is level 3 evidence
to support the use of eccentric exercise to improve quadriceps strength after ACL reconstruction.

Results of Search
Four relevant studies58 were located and categorized as
shown in Table 1 (based on Levels of Evidence, Centre
for Evidence-Based Medicine, 2011).

Best Evidence

Search Strategy

The studies listed in Table 2 were identified as best

evidence and selected for inclusion in this critically
appraised topic (CAT). These studies were selected
because they had a level of evidence of grade 37,8 or
higher,5,6 studied an eccentric-exercise intervention, and
reported the effect of the intervention on quadriceps
strength in the ACL-reconstructed limb.

Terms Used to Guide Search Strategy

Patient/Client group: ACL or anterior cruciate ligament
Intervention/Assessment: eccentric training or
eccentric exercise
Comparison: none
Outcome: quadriceps strength

Implications for Practice,

Education, and Future Research

Sources of Evidence Searched

PubMed
CINHAL
SPORTDiscus
Pertinent studies cross-referenced to identify articles
that met inclusion criteria but were not located during
the original database search

The 4 studies58 reviewed in this CAT support the use

of eccentric strengthening after ACL reconstruction to
improve postoperative quadriceps strength. In patients
recovering from ACL reconstruction, this CAT also indicates that eccentric exercise is more effective at restoring
quadriceps strength than concentric exercise.5,6 However,
due to the variation in time to initiate eccentric exercise
and the devices used to eccentrically train the participants,
the true effect of eccentric strengthening on quadriceps
strength in the ACL-reconstructed limb is still unknown.
Early postoperative eccentric strength training on
the ACL-reconstructed limb was compared with concentric strength training in 2 of the studies included in
this CAT.5,6 Based on the available literature, eccentric
strength training on the ACL-reconstructed limb seems
to produce greater quadriceps strength immediately after
ACL reconstruction5 and up to 1 year postsurgery.6 It
should be noted, however, that results from the 1-yearpostsurgery study6 are a follow-up on the same cohort
of ACL-reconstructed subjects from the initial study.5
Although additional subjects were recruited and added
to the data reported from the 1-year-postoperative study,6

Inclusion and Exclusion Criteria

Inclusion Criteria
Studies with a cohort of subjects who had undergone
unilateral ACL reconstruction
Studies using eccentric strengthening to increase
postoperative quadriceps strength
Level 3 evidence or higher
Limited to humans
Limited to English
Published in the last 10 years (2002 to February 4,
2012)

Table 1 Summary of Study Designs of Articles Retrieved

Level of evidence

Study design

Number located

Reference

Randomized control trial

Gerber et al5

Cohort

Gerber et al6
Coury et al7
Brasileiro et al8

152

Intervention
Initiation: 3 wk postsurgery
Device: ECC group used an eccentric
ergometer (Eccentron). TRAD group
used an concentric ergometer.
Length of intervention: 12 wk
Dose: 23 times per wk for 30 min

Initiation: 3 wk postsurgery

Device: ECC group used an eccentric

ergometer (Eccentron). TRAD group
used a concentric ergometer.

Length of intervention: 12 wk

Dose: 23 times per wk for 30 min

Dose: 2 times per wk, 3 sets of 10 repetitions at a velocity of 30/s

Length of intervention: 12 wk

Device: ACL reconstructed subjects used

a Biodex System 3 isokinetic dynamometer.

Initiation: 9 mo postsurgery

Controls: history of knee injury, equilibrium disorders, and/or current knee pain.

Exclusion criteria: ACL: other associated

injuries, pain, or effusion in the ACL limb
or uninvolved limb.

Exclusion criteria: History of lower

extremity fracture or ACL surgery,
concomitant PCL injury, or significant
articular cartilage damage or meniscal
injury.

Exclusion criteria: History of lower

extremity fracture or ACL surgery,
concomitant PCL injury, or significant
articular cartilage damage or meniscal
injury.

Dose: 2 times per wk, 3 sets of 10 repetitions at a velocity of 30/s

Length of intervention: 12 wk

Device: Biodex System 3 isokinetic

dynamometer

Initiation: 9 mo postsurgery

Exclusion criteria: History of knee

injury to the contralateral knee or experience of knee-joint pain during the
intervention.

9 sedentary ACL-reconstructed men

(age 31.3 5.8 y) were recruited 9.4
0.7 mo postsurgery.

5 male ACL-reconstructed subjects (age

32 7.8 y, height 1.73 0.003 m, weight
80 14 kg) were recruited 9 1.3 mo
postsurgery, and 10 male healthy controls
(age 21.5 2.8 y, height 1.68 0.004 m,
weight 65 k kg) were recruited for postintervention gait comparisons.

40 ACL-reconstructed patients randomly

assigned to concentric (TRAD; n = 20;
8 female, 12 male; age 29.3 9.7 y)
or eccentric exercise (ECC; n = 20; 8
female, 12 male; age 29.3 9.7 y) intervention. Subjects matched by surgical
procedure, sex, and age.

32 ACL-reconstructed patients randomly

assigned to concentric (TRAD; n =
16; 7 female, 9 male; age 31.0 9.8 y)
or eccentric exercise (ECC; n = 16; 7
female, 9 male, age 29.4 9.4 y) intervention. Subjects matched by surgical
procedure, sex, and age.

Participants

Brasileiro et al8

Coury et al7

Gerber et al6

Gerber et al5

Characteristic

Table 2 Characteristics of Included Studies

153

Outcome measures

Secondary outcomes: Hop distance

on the ACL-reconstructed limb. Knee
effusion quantified by midpatellar joint
circumference. Knee stability quantified via a KT-1000 knee arthrometer.
Self-reported outcomes assessed via the
ADLS-KOS, Tegner Activity Scale, and
Lysholm Knee Rating Scale.

Primary outcome: Quadriceps peak

torque assessed via an isokinetic dynamometer concentrically at 60/s.

Primary outcome: Quadriceps peak

torque assessed via an isokinetic dynamometer concentrically at 30/s. Data
were collected at baseline (9 mo postsurgery) and after the intervention.
Secondary outcomes: Knee-flexion angles
recorded while subjects walked on a
treadmill at a speed of 5.0 km/h.

Primary outcome: Quadriceps femoris

and gluteus maximus muscle CSA quantified via MRI measured 3 wk and 1 y
postsurgery on the ACL-reconstructed
limb.
Secondary outcomes: Quadriceps peak
torque assessed via an isokinetic dynamometer concentrically at 60/s. Hop
distance on the ACL-reconstructed limb.
Knee stability quantified via a KT-1000
knee arthrometer. Self-reported outcomes assessed via the ADLS-KOS,
Tegner Activity Scale, and Lysholm
Knee Rating Scale.

(continued)

Secondary outcomes: Quadriceps

muscle activity quantified by EMG.
Quadriceps femoris CSA quantified via
MRI.

Primary outcome: Quadriceps peak

torque measured via an isokinetic
dynamometer eccentrically at 30/s and
120/s and isometrically. Data collected
at baseline (pretraining) and after 6 wk
and 12 wk of eccentric training.

154

Primary findings: Compared with preoperative testing, ECC subjects demonstrated significantly greater quadriceps
peak torque after the intervention at 26
wk (P .001), but the TRAD group did
not (P = .74).

Main findings

PEDro 6/10

Validity score

PEDro 6/10

Secondary findings: Strengthquadriceps peak-torque gains were significantly greater in the ECC group than
in the TRAD group (P .001). Hop
distanceincreased significantly in
the ECC group (P .001) by a magnitude of approximately 50%. Knee
laxityno significant difference was
observed in anteroposterior laxity
between the ECC and TRAD groups (P
= .56). Self-reported outcomes compared with preoperative values, scores
on the ADLS-KOS, Lysholm Knee
Rating Scale, and Tegner Activity Scale
improved significantly in both groups
(P .001); no group differences were
observed.

PEDro 4/10

PEDro 3/10

Secondary findings: EMG activitysignificant increases in the vastus

medialis oblique (VMO) and vastus
lateral (VL) were observed only during
the first 6 wk of training (VMO, P =
.037; VL, P = .042); muscle activity did
not change in the rectus femoris at any
time point (P > .05). CSAsignificant
hypertrophy was observed in the distal
portion of the quadriceps by the end
of the intervention (P = .038) but not
during the first 6 wk (P = .48). The
increase in distal quadriceps CSA was
attributed to the significant hypertrophy
observed in the vastus medialis at 6 wk
(P = .029) and after 12 wk of training
(P = .009).

Primary findings: Quadriceps peak

torque in the eccentric evaluation of
30/s significantly increased by the 6th
(P = .031) and 12th wk (P = .007) of
the intervention. Significant increases
in quadriceps peak torque were also
observed in the eccentric evaluation at
120/s (P = .041) and isometric contraction (P = .039) after the intervention.

Primary findings: ACL-reconstructed

subjects quadriceps torque increased by
25% after the intervention (P = .02).

Primary findings: From 3 wk postsurgery, quadriceps femoris muscle volume

of the ACL-reconstructed limb increased
significantly in both groups (P .001).
Quadriceps femoris muscle volume
increased by more than 50% in the ECC
group compared with the TRAD group
(P .001). Gluteus maximus volume
also increased significantly from 3 wk
postsurgery to 1 y after ACL reconstruction (P .001) and improved by more
than 50% in the ECC group compared
with the TRAD Group (P < .05).
Secondary findings: Knee-flexion
anglesincreased in the ACL-reconstructed group after the intervention
from 51 of flexion at baseline to 58
postintervention (P .001). Control
subjects walked with 57 of flexion, indicating that ACL subjects walked more
like controls after the intervention. Knee
valgus anglesincreased in the ACLreconstructed group after the intervention
from 12 of knee adduction at baseline to
24 postintervention (P < .05). Control
subjects walked with 15 of knee adduction, indicating that ACL subjects walked
with more knee adduction than healthy
controls after the intervention.

Brasileiro et al8

Coury et al7

Gerber et al6

Abbreviations: ACL indicates anterior cruciate ligament; PCL, posterior cruciate ligament; ADLS-KOS, Activity of Daily Living ScaleKnee Outcome Survey; CSA, cross-sectional area; PEDro, Physiotherapy Evidence
Database Scale.

Level of evidence

Secondary findings: Hop distance

compared with preoperative testing, the
ECC group means distance increased
significantly after the intervention (P <
.01) but the TRAD groups did not (P =
.17). Knee effusionno significant differences were noted before surgery, after
surgery, or between the ECC and TRAD
groups (P > .05). Knee laxityno significant differences in anteroposterior
laxity were observed between groups
at 15 or 26 wk postsurgery (P > .05).
Self-reported outcomesno significant
group-by-time interactions were found
for scores on the ADLS-KOS (P > .05).
Tegner scale decreased to a lesser extent
in the ECC group than in the TRAD
group at 26 wk postsurgery (P = .02).

Gerber et al5

Characteristic

Table 2 (continued)

Eccentric Strengthening After ACL Reconstruction 155

the majority of participants had gains in quadriceps

strength reported at both time points (Table 2). Eccentric
strengthening programs initiated approximately 9 months
postreconstruction also seem to positively influence
quadriceps strength.7,8 The results from all 4 studies are
in line with previous literature that has demonstrated that
eccentric strengthening is more effective at overloading
the muscle, resulting in a greater potential for muscle
hypertrophy.1,2

Clinical Considerations
Clinicians implementing eccentric-exercise protocols
after ACL reconstruction should consider the device that
will be used to deliver the intervention, the intensity of
the exercise, and the time after ACL reconstruction to
initiation of the eccentric strengthening.

Eccentric-Exercise Device
Devices and time in which devices were used to initiate
eccentric-strengthening programs after ACL reconstruction varied across studies. An eccentric ergometer with
motor-propelled pedals that moved toward (negatively
loaded) the participants while they resisted the pedals
(Eccentron, Denver, CO) was used in 2 studies,5,6 while
other research 7,8 used an isokinetic dynamometer.
Although results using the eccentric ergometer were
superior to those found using the concentric ergometer,5,6
no direct comparison of an eccentric ergometer with an
isokinetic dynamometer is currently available. Hence, it
is unknown which device is better or if they are equally
effective at producing improvements in quadriceps
strength. Another device variation among studies was
the range of motion used to deliver the intervention. At
this point in time, only 1 research group5,6 has provided
specific range-of-motion recommendations (2060).
Although there is short-term evidence that eccentric exercise can be employed safely within this range of motion,5
the long-term effects of this protocol are currently
unknown. Aside from these results, clinicians will need
to consider the availability of the device when developing
an eccentric-exercise protocol. Given that the eccentric
ergometer is a specialized device, the availability of this
equipment may be limited in traditional clinic settings.

Time to Initiation of Eccentric Exercise

Interventions using an isokinetic dynamometer initiated
treatment approximately 9 months after ACL reconstruction,7,8 while interventions using an eccentric ergometer
initiated treatment 3 weeks after surgery on the involved
limb.5,6 It is possible that investigations using an isokinetic dynamometer delayed onset of treatment initiation
due to the nature of the device involving an open-kineticchain (OKC) exercise. Given that the potential for strain
on the ACL graft is higher during OKC exercises than
in the closed kinetic chain,9 OKC exercises have been
discouraged in the early postoperative stages. Clinicians

deciding to implement an eccentric exercise protocol after

ACL reconstruction will need to take equipment limitations and time postsurgery into consideration.

Intensity of Eccentric Exercise

The 2 studies that trained subjects via an eccentric ergometer used the Borg Rating of Perceived Exertion Scale10
to grade intensity, whereby subjects were allowed to
gradually progress to a hard intensity over the course
of a 12-week intervention.5,6 The 2 studies that used the
isokinetic dynamometer had participants perform 3 sets
of 10 maximal eccentric contractions at 30/s twice a
week for 12 weeks.7,8

Safety
It is important to note that there is mounting evidence
that eccentric exercises can be employed safely after
ACL reconstruction.5 However, the long-term safety and
effectiveness of eccentric exercise is unknown. Future
investigations should consider using more advanced
measurements of safety after ACL reconstruction, such
as enzyme-linked biomarkers11 or magnetic resonance
imaging to assess knee-joint health.12

Clinical Recommendation
In the course of clinical practice, we conclude that eccentric strengthening after ACL reconstruction is an effective
therapy that can positively influence quadriceps strength.
Future trials using eccentric strengthening after ACL
reconstruction should measure the effect of eccentric
strengthening on other important ACL outcome measures such as quadriceps activation and lower extremity
mechanics.

References
1. Enoka RM. Eccentric contractions require unique activation strategies by the nervous system. J Appl Physiol.
1996;81(6):23392346. PubMed
2. LaStayo PC, Woolf JM, Lewek MD, Snyder-Mackler L,
Reich T, Lindstedt SL. Eccentric muscle contractions:
their contribution to injury, prevention, rehabilitation, and
sport. J Orthop Sports Phys Ther. 2003;33(10):557571.
PubMed
3. Wilk KE, Reinold MM, Hooks TR. Recent advances in the
rehabilitation of isolated and combined anterior cruciate
ligament injuries. Orthop Clin North Am. 2003;34(1):107
137. PubMed doi:10.1016/S0030-5898(02)00064-0
4. Gerber JP, Marcus RL, Dibble LE, Greis PE, LaStayo PC.
Early application of negative work via eccentric ergometry
following anterior cruciate ligament reconstruction: a case
report. J Orthop Sports Phys Ther. 2006;36(5):298307.
PubMed
5. Gerber JP, Marcus RL, Dibble LE, Greis PE, Burks RT,
Lastayo PC. Safety, feasibility, and efficacy of negative

156Lepley and Palmieri-Smith

work exercise via eccentric muscle activity following

anterior cruciate ligament reconstruction. J Orthop Sports
Phys Ther. 2007;37(1):1018. PubMed doi:10.2519/
jospt.2007.2362
6. Gerber JP, Marcus RL, Dibble LE, Greis PE, Burks RT,
LaStayo PC. Effects of early progressive eccentric exercise on muscle size and function after anterior cruciate
ligament reconstruction: a 1-year follow-up study of a
randomized clinical trial. Phys Ther. 2009;89(1):5159.
PubMed doi:10.2522/ptj.20070189
7. Coury HJ, Brasileiro JS, Salvini TF, Poletto PR, Carnaz
L, Hansson GA. Change in knee kinematics during gait
after eccentric isokinetic training for quadriceps in subjects
submitted to anterior cruciate ligament reconstruction.
Gait Posture. 2006;24(3):370374. PubMed doi:10.1016/j.
gaitpost.2005.11.002
8. Brasileiro JS, Pinto OMSF, Avila MA, Salvini TF. Functional and morphological changes in the quadriceps muscle
induced by eccentric training after ACL reconstruction.
Revista Brasileira de Fisioterapia. 2011;15(4):284290.
PubMed doi:10.1590/S1413-35552011005000012

9. Bynum EB, Barrack RL, Alexander AH. Open versus

closed chain kinetic exercises after anterior cruciate
ligament reconstruction: a prospective randomized
study. Am J Sports Med. 1995;23(4):401406. PubMed
doi:10.1177/036354659502300405
10. Noble BJ, Borg GA, Jacobs IRA, Ceci R, Kaiser P. A
category-ratio perceived exertion scale: relationship to
blood and muscle lactates and heart rate. Med Sci Sports
Exerc. 1983;15(6):523528. PubMed
11. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior cruciate ligament reconstruction:
a prospective, randomized, double-blind comparison
of programs administered over 2 different time intervals. Am J Sports Med. 2005;33(3):347359. PubMed
doi:10.1177/0363546504268406
12. Haughom B, Schairer W, Souza RB, Carpenter D,
Ma CB, Li X. Abnormal tibiofemoral kinematics following ACL reconstruction are associated with early
cartilage matrix degeneration measured by MRI T1rho.
Knee. 2012;19(4):482487. PubMed doi:10.1016/j.
knee.2011.06.015