Isokinetic testing protocol-based discharge criteria after anterior ligament reconstruction: A systematic review

Abstract

BACKGROUND:

The return to activities and sports after the anterior cruciate ligament (ACL) reconstruction is a critical decision.

OBJECTIVE:

To verify the most used elements during the isokinetic evaluation for discharge after ACL reconstruction.

METHODS:

Systematic review (PROSPERO CRD42021224433). Research in the literature: PubMed, Medline, SciELO, Lilacs, CENTRAL, PEDro, Web of Science and Embase, in February 2022. Studies that performed isokinetic evaluation during the discharge period in male patients aged 18 to 59 years after ACL reconstruction. Descriptive synthesis on the most used parameters during isokinetic evaluation as a discharge criteria after ACL reconstruction.

RESULT:

Twenty-three studies involving 1,792 participants were included. Medium and high quality evidence identified that most isokinetic evaluations targeted only muscle strength after rehabilitation of the ACL (peak moment).

CONCLUSION:

The most used elements during the isokinetic evaluation were: angular velocity of 60^∘/s, 1 set of 5 repetitions, concentric mode and peak moment.

Keywords

Anterior cruciate ligament muscle strength dynamometer return to sport

1. Introduction

The knee joint is constantly subject to injury, since its stability depends on the complex anatomy of muscles and ligaments [1, 2, 3]. The anterior cruciate ligament is responsible for preventing anterior sliding of the tibia in relation to the femur, knee hyperextension and rotational movements [4, 5, 6]. After anterior cruciate ligament injury, surgical reconstruction is often recommended to restore anterior knee stability [7, 8]. The return to activities and sports after the anterior cruciate ligament reconstruction is a critical decision, because the criteria used for discharge are fundamental to prevent injury recurrences, to ensure patient’s best performance, and even to reduce the costs with health treatments [9].

The isokinetic dynamometer is considered the gold standard method for strength evaluation, being fundamental to measure muscle rebalance and joint function [4, 10]. The device imposes resistance with constant velocity that adapts to the patient’s strength, measuring parameters such as moment (Newton meter), angular velocity, total muscle work (Joules) and muscle power (Watts), providing numerical results and graphs [11]. The isokinetic dynamometer performs a quantitative evaluation of muscle function, its measurements are safe, objective and reproducible, besides being able to identify the patient’s deficiencies, establishing a criterion for discharge and return to sport [12].

Undheim et al. [13]. conducted a systematic review to report isokinetic evaluation protocols to assess muscle strength of patients undergoing anterior cruciate ligament reconstruction [13]. However, the study was conducted with low methodological quality, because the data were extracted only by the main author, causing a high risk of bias to the results. Moreover, the non-characterization of the sample studied regarding sex may interfere with the results due to the variation of strength between sexes [14]. The literature searches were carried out in 2013. Currently, new studies have been published, which may change the results presented.

Roe et al. [15] investigated the criteria for returning to sport and muscle strength was present in 50 studies. Of these studies, 33.3% evaluated isokinetic strength at 60^∘/s. However, the study was developed to examine similarities and differences in tests for return to sport, i.e., the isokinetic criteria and parameters used were not specifically investigated, which are fundamental to measure muscle stability so that patients return to daily and sports activities more safely and with lower risk of injury recurrences. Thus, a systematic review investigating isokinetic parameters is necessary, to verify in detail which isokinetic parameters are being used for discharge and return to sport. Therefore, the aim of this study was to verify which are the most used parameters in the isokinetic evaluation for discharge after anterior cruciate ligament reconstruction.

2. Methods

This systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [16] guidelines. The review protocol was prospectively recorded in the PROSPERO database (CRD42021224433).

2.1 Search strategy

Systematic searches were performed in the electronic databases: PubMed (MEDLINE), SciELO, LILACS, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, Web of Science and EMBASE, from the oldest records until February 24, 2022, without restrictions regarding language and year of publication.

For the search strategy, terms and words related to the subject were used, in addition to the descriptors present in the DeCS (Descriptors in Health Sciences) and meSH (Medical Subject Headings) PubMed: “Anterior cruciate ligament” AND “isokinetic dynamometer”. The detailed search strategies used in each database are described in Appendix 1.

2.2 Inclusion and exclusion criteria

The studies were considered for inclusion if they met the following criteria: (1) any study design except: reviews of any nature, experience report, in vivo studies, in vitro studies, animal studies and case reports, (2) male participants aged between 18 and 59 years, (3) and perform isokinetic evaluation during discharge in patients submitted to or after anterior cruciate ligament reconstruction. Studies (1) unavailable full text and if there was no response from the authors were excluded (2) there was no specification in the sample sex (3) no full text was found and there was no response from the authors.

2.3 Studies selection

The studies selection process included: (1) analysis and selection by screening of titles, (2) analysis and selection by reading abstracts and (3) analysis and selection by reading the full texts, taking into account the inclusion criteria established. Potentially eligible studies were also researched by reading the reference lists. Three independent reviewers extracted the data (ACJC, LZRS and LGF) and, in case of disagreement, reviewers discussed to reach consensus.

2.4 Data extraction

Figure 1.

Studies selection process and inclusion process.

A study-based data extraction form [17] was elaborated to record information on: (1) year of publication, (2) study design, (3) characteristics of participants, and (4) isokinetic evaluation protocol. Three independent reviewers extracted the data (ACJC, LZRS and LGF) and, in case of divergence; reviewers discussed to reach consensus.

2.5 Protocols quality assessment

The quality assessment was performed through a personalized checklist [18]. adapted to the isokinetic instrument, because no standardized quality assessment guidelines applicable to the the purpose of this study were identified, in addition to the included studies design heterogeneity. The quality checklist consisted of 20 items, each item was evaluated with 0 (not described), 1 (limited description) and 2 (described appropriately), Appendix 2. Items 10 to 15 were adapted to the isokinetic dynamometer instrument, without prejudice to the total score. According to the scale score, the studies are classified as low quality (score $<$ 33.3%), average quality (score between 33.4 and 66.7%) or high quality (score $>$ 66.8%). Three independent reviewers performed the quality assessment (ACJC, LZRS and LGF) and, in case of disagreement; consensus was reached by discussion.

Due to some items adaptation in the personalized checklist, relative reliability was performed to observe the reliability among the study evaluators. Reliability was calculated by the Intraclass Correlation Coefficient (ICC), with a 95% confidence interval (95% CI), using the two-way mixed effects model, absolute agreement, a single evaluator model. The ICC is interpreted according to the following guidelines: values lower than 0.5 indicate low reliability, values between 0.5 and 0.75 indicate moderate reliability, values between 0.75 and 0.9 indicate good reliability, and values higher than 0.90 indicate excellent reliability as suggested by Koo and Lee [19].

2.6 Data analysis

The variables measured in the study were described through qualitative analysis and narrative synthesis of the findings.

3. Results

3.1 Studies inclusion

The databases search resulted in 7,782 studies, of which 3,418 were excluded after reading the titles and abstracts, and 3,517 were considered potentially eligible. In addition, a total of 79 studies were excluded after reading the full text and 5 studies were not found, although contact was made with the authors by e-mail, requesting the full text. An abstract was considered potentially eligible but was not included in the analysis because the full text could not be assessed [20].

Twenty studies were included through the databases and three studies were included through the reference lists of the included studies. Thus, 23 studies met the inclusion criteria and were included in the review [21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43]. Furthermore, f [21,22,23,24, 25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43] our additional potentially eligible studies were found [44, 45, 46, 47] in the selected studies reference lists, but were not included, since the full text was not found [44] even after being requested; the study was not found [47] there was no specification of the sample gender [45, 46]. and the authors’ contact was not available. The entire eligibility assessment process is described in Fig. 1.

3.2 Studies characteristics

Twenty-three studies were included in the analysis ( $n=$ 1,792 participants). The studies were published between 2004 [24] and 2021 [30, 36] with cohort, case-control and cross-sectional design. Participants were recruited from different sources, such as cases of specialized orthopedic surgeons [25, 30, 38, 43]. directly from soccer teams [30, 34, 36] medical records [28] hospitals [39, 41] from a potential cohort [21, 37] and through a rehabilitation program in the clinic [23]. The other studies did not describe how recruitment was performed [22, 24, 26, 27, 29, 31, 32, 33, 35, 40, 42]. Isokinetic evaluations were performed between 3 [21, 27, 41]. 4 [24, 28, 29, 32, 42]. 6 [21, 27, 29, 41]. 8 [28, 37]. 9 [36, 38]. and 12 months [27, 29, 41]. Nine studies did not mention when the evaluation was performed [22, 23, 25, 26, 30, 31, 35, 40, 43].

Table 1
Description of the studies included in the analysis

Year of study	Study design	Participants characteristics	Isokinetic dynamometer	Isokinetic evaluation	Evaluation of quality scale adapted to isokinetic
Herrington et al. [30]	Transverse	N $=$ 15 professional full-time football players • Age 22.3 $\pm$ 3.1 years • Body mass 81.0 $\pm$ 11.5 kg • Height 1.75 $\pm$ 0.1 m	Biodex Medical Systems, Shirley, NY, EUA	Quadriceps eccentric and concentric isokinetic strength • Isokinetic test: 5 practice repetitions, 3 minutes of rest, then 5 maximum eccentric contractions of quadriceps and followed by concentric contractions of quadriceps, at 60^∘/s in a knee flexion range of 0–90^∘. All data were corrected by severity and normalized in relation to body mass. TP and ILS were analyzed. Quadriceps isometric strength test • Isokinetic test: 5 practice repetitions, followed by 5 maximum. Quadriceps muscle inhibition was evaluated during a quadriceps maximum isometric contraction with the interpolated contraction technique.	85.0%
Milutinovic et al. [36]	Transverse	N $=$ 8 elite football players, male • Age 25.5 $\pm$ 3.9 years • Body mass 78.9 $\pm$ 4.5 kg • Height 1.83 $\pm$ 0.04 m	Humac-Norm isokinetic dynamometer (Computer Sports Medicine Inc., Stoughton, USA)	• Warm-up: stationary bike for 5 minutes, passive stretching and 3 submaximal knee flexions/extensions separately for each leg at 60^∘/s and 180^∘/s; • Isokinetic test: extend the lower leg to 90^∘ until it reaches the full length of 180^∘ and complete 5 cycles (5 flexions and 5 extensions). The recovery time between sets was 2 minutes. The PM, H/Q ratio and ILS were evaluated.	71.2%
Akinci et al. [22]	Transverse	N $=$ 23 male patients • Age 28.52 $\pm$ 6.88 years • Body mass 26.34 $\pm$ 4.17 kg/m² • Height 180.60 $\pm$ 6.30 cm		• Familiarization: the test was practiced once; • Isokinetic test: concentric-concentric contraction, 5 repetitions at 60^∘/s and 10 repetitions at 180^∘/s. PM was recorded as Nm/kg. The Indices of Concentric Quadriceps and Hamstring were calculated and recorded at 60^∘/s and 180^∘/s [Index (%) (Peak moment MI/Peak moment MNI) x100.	68.7%
Carolan et al. [25]	Transverse	N $=$ 344 athletes, male Primary cohort (298) • Age 24.16 $\pm$ 4.6 years • Height 179.7 $\pm$ 6.11 cm • Weight 82.8 $\pm$ 10.2 kg Cut review (46) • Age 24.9 $\pm$ 3.93 years • Height 180.1 $\pm$ 6.2 cm • Weight 83.0 $\pm$ 7.4 kg	Humac Norm Isokinetic Extremity System (Computer Sports Medicine)	• Warm-up: dynamic standardized for 5 minutes; • Familiarization: set of exercises; • Isokinetic test: 5 repetitions of knee concentric extension and flexion were performed at 60^∘/s, at a defined range of motion from 0^∘ to 100^∘, using gravity correction. Quadriceps and hamstring strength measurements were recorded in terms of PM and ILS.	82.5%

Table 1, continued
Year of study	Study design	Participants characteristics	Isokinetic dynamometer	Isokinetic evaluation	Evaluation of quality scale adapted to isokinetic
O’Connor et al., 2020 [38]	Case-Control	N $=$ 452 athletes, male • Age 25.5 $\pm$ 6.1 years	Cybex Norm, Computer Sports Medicine Inc	• Warm-up: 2-minute run, 5 body weight squats, 2 submaximum jumps and 3 maximums with counter-movement on one leg; • Familiarization: 1 set on the device; • Isokinetic test: 3 sets of 5 repetitions at 60^∘/s. In the first set, warm-up and familiarization was performed, while maximum effort was required in the second and third sets. Quadriceps and hamstrings PM, PO and ILS were measured.	75.0%
Krzemińska et al., 2020 [33]	Not informed	N $=$ 40 men ACLR Group (20) • Age 27.80 $\pm$ 5.48 years • Height 183.60 $\pm$ 7.83 cm • Body mass 82.75 $\pm$ 9.00 kg Control group (20) • Age 24.85 $\pm$ 3.12 years • Height 181.85 $\pm$ 5.45 cm • Body mass 82.95 $\pm$ 9.16 kg	HUMAC NORM (CSMI Computer Sports Medicine, Inc., Stoughton, MA, EUA)	• Warm-up : stationary bike for 12 minutes; • Isokinetic test: 5 repetitions were performed at 60^∘/s and 8 repetitions at 180^∘/s, with an interval of 2 minutes. In the control group, the right knee was measured first, then the left knee, while in the RLCA group the MNI was measured first, then the MI. The PM, H/Q ratio and the ILS were measured.	65.0%
Abellaneda et al., 2019 [21]	Transverse	N $=$ 46 • 18 to 50 years Cohort 1: 20 (29.1 $\pm$ 9.4) Cohort 2: 26 (30.1 $\pm$ 8.6)	Cybex (Humac)	• Warm-up: stationary cycle ergometer at 50 watts for 5 minutes; • Familiarization: participants performed 2 attempts at each velocity; • Isokinetic test: 3 repetitions at 60^∘/s and 240^∘/s in concentric mode and 30^∘/s in eccentric mode. The device used is calibrated annually. PM for extensors and flexors muscles were measured and recorded bilaterally.	76.2%
Pelegrinelli et al. [40]	Case-Control	N $=$ 14 male professional football players or physically active ACL group (7) • Age 23 (19–25) years • Height 181.5 (173.2–192) cm • Body mass 86.4 (70–102) kg Control group (7) • Age 21.8 (19–24) years • Height 180.5 (176–185) • Body mass 78.5 (76–80) kg	Biodex System 4^® (Biodex Medical System Inc., Shirley, NY).	• Warm-up: stationary bike at 30 km/h without resistance for 10 minutes; • Isokinetic test: concentric mode at 60^∘/s, 120^∘/s and 300^∘/s, for knee flexion and extension with sampling frequency of 100 Hz. PM was evaluated.	67.5%

Table 1, continued
Year of study	Study design	Participants characteristics	Isokinetic dynamometer	Isokinetic evaluation	Evaluation of quality scale adapted to isokinetic
O’Malley et al., 2018 [39]	Transverse	N $=$ 162 athletes, male ACLR Group (118) • Age 23.6 $\pm$ 5.8 years • Height 182.6 $\pm$ 6.7 cm • Body mass 81.9 $\pm$ 10.5 kg Control group (44) • Age 24.1 $\pm$ 3.6 years • Height 183.1 $\pm$ 6.5 cm • Body mass 82.7 $\pm$ 8.0	Cybex Norm; Computer Sports Medicine Inc, Stoughton, MA	• Warm-up: 5 repetitions of extension and flexion from 50% to 75% and 1 attempt of 100% of maximum effort. • Isokinetic test: knee concentric extension and flexion PM were evaluated at 60^∘/s. After warm-up, and a rest period of 60 seconds, participants were instructed to complete 2 sets of 5 repetitions of maximum extension and flexion. The procedure was then repeated in the operated limb. The PM, PO and ILS were analyzed.	75.0%
Seo et al. [41]	Retrospective cohort	N $=$ 73 male patients • Age 30.67 $\pm$ 9.81 years • Height 172.90 $\pm$ 5.54 cm • Weight: 75.49 $\pm$ 10.03 kg	Biodex System 3 (Biodex Medical Systems, Shirley, New York, EUA)	• Isokinetic test: concentric mode at 60^∘/s. Participants performed 2 sets of 5 maximum repetitions with a rest of 30 seconds between sets. The PM values were used to evaluate knee flexion-extension muscle strength. The H/Q ratio and the ILS were analyzed.	65.0%
Kadija et al. [32]	Transverse	N $=$ 15 male athletes • Age 22 $\pm$ 4 years • Height: 180.3 $\pm$ 4.0 cm • Body mass 84.0 $\pm$ 11.1 kg	Kin-Com isokinetic dynamometer (Chatex Corp., Chattanooga, TN, USA)	• Warm-up: stationary bike for 5 minutes, followed by passive stretching exercises; • Familiarization: 1 set of two submaximal contraction pre-tests was performed for each muscle group; • Isokinetic test: isometric mode. Two maximal voluntary isometric contractions were performed for quadriceps and hamstrings at 60-second intervals, sustaining contraction for 5 seconds. Tests with visible initial countermovement were excluded and an extra test was performed. The H/Q ratio and the ILS were calculated.	62.5%
Kyritsis et al. [34]	Not informed	N $=$ 158 male professional athletes ACL rupture group (26) • Age 22 $\pm$ 5 years • Height 177.5 $\pm$ 6 cm • Weight 72.6 $\pm$ 13.5 kg ACL rupture-free group (132) • Age 21 $\pm$ 4 years • Height 176.3 $\pm$ 7.7 cm • Weight 73.5 $\pm$ 12 kg	Biodex dynamometer (System 4, Biodex Medical Systems, Shirley, New York, USA)	• Isokinetic test: concentric mode, performed for involved and not involved quadriceps and hamstrings. 5 repetitions of knee extension and knee flexion for each leg at 60^∘/s and 180^∘/s, and 20 repetitions at 300^∘/s. PM, percentage of peak moment in relation to body weight, fatigue at work, average power and hamstrings and quadriceps peak moment ratio were recorded.	65.0%
Cvjetkovic et al. [26]	Prospective study	N $=$ 40 men Experimental group -ACLR (20) Control group -Healthy (20)	Biodex System 4 Pro isokinetic dynamometer	• Warm-up: exercise bike for 6 minutes at submaximal level; • Familiarization: 2 previous tests using the Biodex System; • Isokinetic test: knee extension and flexion, concentric-concentric mode, at 60^∘/s (5 repetitions) and 180^∘/s (10 repetitions). The MNI was tested first and ROM was 0-90^∘, with gravity correction. The parameters used were PM, PO and H/Q ratio, calculated automatically by the device.	65.0%

Table 1, continued
Year of study	Study design	Participants characteristics	Isokinetic dynamometer	Isokinetic evaluation	Evaluation of quality scale adapted to isokinetic
Czaplicki et al. [27]	Not informed	N $=$ 29 men • Age 27.5 $\pm$ 5 years • Height 176.8 $\pm$ 5.1 cm • Average body mass 81.8 $\pm$ 10.6 kg	Biodex System 3-PRO (Biodex Medical Systems Inc., Shirley, NY).	• Warm-up: cycle ergometer for 5 minutes; • Familiarization: 3 attempts with moderate muscle involvement; • Isokinetic test: ROM in the joint was limited to 90^∘ and the MNI was evaluated first. The knee flexion and extension PM were evaluated at 60^∘/s and 180^∘/s. The test included 1 set of 5 extension and flexion movements at 60^∘/s and 10 attempts at 180^∘/s. The parameters used were PM, H/Q ratio and normalized TW.	62.5%
Dagnoni et al. [28]	Applied study. Descriptive quantitative approach and documentary design	N $=$ 33 men • Age: 20 to 30 years • Weight 78.6 $\pm$ 7.58 kg • Height 1.78 $\pm$ 0.06 m • IMC 24,76 $\pm$ 2,20 kg/m²	Cybex (Norm 700 model)	• Warm-up: cycle ergometer for 5 minutes; • Familiarization: 2 submaximal contractions and 1 maximum contraction; • Isokinetic test: The MNI was tested first. The knee ROM was 100^∘ flexion to 0^∘ extension. Concentric mode at 60^∘/s with 3 maximum repetitions. The H/Q and work ratios at 60^∘/s were measured. The evaluations were performed by only one experienced reviewer.	78.7%
Mohammadi et al. [37]	Cohort	N $=$ 63 male athletes PBTB Group (21) • Age 24.9 $\pm$ 2.8 • Height 178.3 $\pm$ 7.8 • Weight 73.3 $\pm$ 8.5 STG Group (21) • Age 25.2 $\pm$ 2.4 • Height 176.9 $\pm$ 7.5 • Weight 73.9 $\pm$ 7.6 Control group (21) • Age 25.4 $\pm$ 2.9 • Height 179.7 $\pm$ 8.1 • Weight 74.6 $\pm$ 7.5	Cybex International, Medway, Massachusetts	• Warm-up: 5 minutes; • Isokinetic test: concentric extension-flexion maximum at 60^∘/s and 180^∘/s while PM was collected. The MNI was tested first.	70.0%
Xergia et al. [43]	Cross-sectional study	N $=$ 44 men ACLR Group (22) • Age 28,8 $\pm$ 11.2 years • Height 1.77 $\pm$ 0.04 m • Body mass 76.8 $\pm$ 10.5 kg Control group (22) • Age 24.8 $\pm$ 9.1 years • Height 1.78 $\pm$ 0.09 m • Body mass 75.8 $\pm$ 19.3 kg	Biodex System 3; Biodex Medical Systems, Inc, Shirley, NY	• Warm-up: ergometer for 5 minutes; • Familiarization: 4 repetitions of submaximal effort; • Isokinetic test: concentric performed at 120^∘/s, 180^∘/s and 300^∘/s. Range of motion was defined from 90^∘ of flexion to total extension 0^∘. The MNI was tested first. Five repetitions were performed. PM and ILS were used.	85.0%

Table 1, continued
Year of study	Study design	Participants characteristics	Isokinetic dynamometer	Isokinetic evaluation	Evaluation of quality scale adapted to isokinetic
Baltaci et al. [23]	Functional comparison	N $=$ 30 • 20 to 35 years; • 15 reconstruction (29.6 $\pm$ 5.9) • 15 healthy (27.0 $\pm$ 6.2)	Cybex 6000 (Cybex International, Inc., Medway, MA, EUA)	• Warm-up: 5 minutes; • Isokinetic test: the test was repeated 5 times at 60^∘/s and 10 times at 180^∘/s. The PM was analyzed.	47.5%
Thiele et al. [42]	Normative data	N $=$ 30 men, recreational sports activities • Age 30.9 $\pm$ 9.4 years • Height 1.76 $\pm$ 0.06 m • Weight 79.3 $\pm$ 8.8 kg • Muscle mass index 25.5 $\pm$ 2.2	Cybex Norm (Lumex Inc., Ronkokoma, NY, USA).	• Warm-up: bicycle for 10 minutes and stretching; • Familiarization: some repetitions using the device; • Isokinetic test: 60^∘/s, 180^∘/s and 240^∘/s in concentric mode and 60^∘/s in eccentric mode, with 5 knee flexion-extension movements at each angular velocity. PM, PO, TW and peak moment angle were analyzed.	47.5%
Dauty et al. [29]	Prospective cohort study	N $=$ 60 (25 $\pm$ 6 years)	Cybex Norm^® (Rankoma, NY, United States)	• Warm-up: bicycle for 10 minutes; • Familiarization: 5 submaximal movements and 2 maximum movements; • Isokinetic test: it was started with any knee randomly. 3 repetitions at 60^∘/s followed by 5 repetitions at 180^∘/s. Recovery of 20 seconds was performed between velocities and PM was analyzed.	73.7%
Lustosa et al. [35]	Case-control	N $=$ 25 men Adapted group (15) • Age 34.5 years ( $\pm$ 8.85) Not adapted group (10) • Age 33.4 years ( $\pm$ 7.53)	Byodex System 3 Pro	• Warm-up: bicycle for 5 minutes and static stretching; • Familiarization: 3 repetitions at each velocity (60^∘/s and 300^∘/s); • Isokinetic test: concentric mode at 60^∘/s and 300^∘/s, 5 repetitions of maximum effort. TW was analyzed.	68.7%
Jamshidi et al. [31]	Not informed	N $=$ 21 • 11 amateur athletes (30 $\pm$ 8 years) • Control: 10 healthy subjects matched by age and activity	Biodex System 3	• Warm-up: stationary bike for 5 minutes; • Familiarization: 5 repetitions of submaximal knee flexion and knee extension at 60^∘/s, and 180^∘/s; • Isokinetic test: The dynamometer was calibrated before the test. Concentric and eccentric PM were recorded after gravity correction at 60^∘/s (3 repetitions), and 180^∘/s (5 repetitions). Maximum strength measurements were collected with 1 minute of rest between velocities. PM and H/Q ratio were analyzed.	67.5%

Table 1, continued

Year of study

Study design

Participants characteristics

Isokinetic dynamometer

Isokinetic evaluation

Evaluation of quality scale adapted to isokinetic

Cardone et al. [24]

Prospective cohort study

=

67 (27.0

\pm

7.6 years)

Cybex 6000 (Cybex, Inc., Ronkonk oma, NY)

•

Warm-up: stationary bike for 10 minutes and 3 flexion-extension movements at each velocity;

•

Isokinetic test: concentric movements of knee flexion and knee extension were evaluated at 60^∘/s, 180^∘/s, and 240^∘/s. 4 repetitions were performed at each velocity, with 1 minute interval between sets. ROM was 90^∘ for the tests performed at 4 and 6 months. The variables were PM and TW.

55.0%

N – Total sample number; ^∘/s – Degrees per second; (Nm) – Newton / meters ; Nm/kg – Newton meter/kg; H/Q ratio – hamstring/quadriceps ratio; MI – Member involved; MNI – Member not involved; IL – Injured limb; UL – Uninjured limb; ILS – Index of limb symmetry; PM- Peak moment; PO – Power; TW – Total work; ROM – Range of motion; km/h – Kilometer/ hour; Kg – Kg; kg/m² – Kilogram / square meter; cm – Centimeters; m – Meters; ACL – Anterior cruciate ligament; ACLR – Anterior cruciate ligament reconstruction; Hz – Hertz; BMI – Body mass index; PBTB – patellar bone-tendon-bone graft; STG – semitendinosus and gracilis tendon graft.

Table 1 presents the characteristics of the studies.

3.3 Warm-up and familiarization

Nineteen studies performed warm-up [21, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 35, 36, 37, 38, 39, 40, 42, 43] and fourteen performed familiarization with the device [21, 22, 25, 26, 27, 28, 29, 30, 31, 32, 35, 38, 42, 43]. before evaluation. The warm-up was performed using an exercise bike or cycle ergometer for 5 to 12 minutes [21, 24, 26, 27, 28, 29, 31, 32, 33, 35, 36, 40, 42, 43]. Lustosa, Fonseca e Andrade (2007) [35]. Thiele et al. [42]. Kadija et al. [32] and Milutinovic et al. [36] in addition to cycling, used stretching for the evaluated muscles. Cardone et al. [24]. O’ Malley et al. [39] and Milutinovic et al. [36] used repetitions using the device as warm-up. O’ Connor et al. [38]. performed running, squats and jumps. Other studies performed warm-up for 5 minutes, without specifying the way of execution [23, 25, 37] and 4 studies did not perform warm-up [22, 30, 34, 41].

Familiarization consisted of repetitions with submaximal force, between 2 and 5 repetitions [28, 29, 31, 32, 43]. Dagnoni et al. [28] and Dauty et al. [29] in addition to the repetitions with submaximal force, performed repetitions with maximum force. Abellaneda et al. [21] and Lustosa et al. [35]. performed repetitions at each velocity evaluated as a form of familiarization. In the study by Cvjetkovic et al. [26] all participants had at least 2 previous tests using the Biodex System. Other studies performed some repetitions using the device [22, 25, 27, 30, 38, 42] and 9 studies did not perform familiarization [23, 24, 33, 34, 36, 37, 39, 40, 41].

3.4 Contraction mode

During the isokinetic evaluation 16 studies used concentric mode [21, 22, 24, 25, 26, 28, 30, 31, 34, 35, 37, 39, 40, 41, 42, 43]. 4 studies used concentric and eccentric mode [21, 30, 31, 42]. 2 studies used the isometric mode [30, 32] and the remaining did not specify the contraction mode used [23, 27, 29, 33, 36, 38].

3.5 Angular velocities

The most used angular velocities were 60^∘/s, evaluated in 21 studies [21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42]. and 180^∘/s, evaluated in 13 studies [22, 23, 24, 26, 27, 29, 31, 33, 34, 36, 37, 42, 43]. Other angular velocities such as 30^∘/s [21]. 120^∘/s [40, 42, 43]. 240^∘/s [21, 24] and 300^∘/s [34, 35, 40, 43]were also observed [21, 24, 34, 35, 40, 42, 43].

3.6 Isokinetic variables

In this review, 20 studies used peak moment to measure muscle strength [21, 22, 23, 24, 25, 26, 27, 29, 30, 31, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43] 5 studies investigated power [26, 34, 38, 39, 42] and 6 studies investigated the total work [24, 27, 28, 34, 35, 42]. The H/Q ratio (Hamstring/quadriceps) was analyzed by 10 studies [22, 26, 27, 28, 31, 32, 33, 34, 36, 41] and limb symmetry index was calculated by 9 studies [25, 30, 32, 33, 36, 38, 39, 41, 43].

3.7 Sets and repetitions

Regarding the set and repetitions during the isokinetic evaluation, 10 studies performed 1 set of 5 repetitions [22, 23, 25, 26, 30, 33, 34, 35, 42, 43]. Baltaci et al. [23]. Cvjetkovic et al. [26]. Czaplicki et al. [27]. Kyritsis et al. [34]. Akinci et al. [22]. Krzemińska et al. [33] used 1 set of 5 repetitions at 60^∘/s and 1 set of 10 repetitions at 180^∘/s, with the exception of Kyritsis et al. [34] who followed these repetitions and added 1 set of 20 repetitions at 300^∘/s and Krzemińska et al. [33] which used 1 set of 8 repetitions at 180^∘/s. Milutinovic et al. [36] performed 5 knee flexion repetitions and 5 knee extension repetitions.

Dauty et al. [29] and Jamshidi et al. [31] performed 3 repetitions at 60^∘/s and 5 repetitions at 180^∘/s. Dagnoni et al. [28] and Abellaneda et al. [21] evaluated with 1 set of 3 repetitions. O’ Malley et al. [39] and Seo et al. [41] used 2 sets of 5 repetitions. Cardone et al. [24] performed 1 set of 4 repetitions and O’Connor et al. [38] 3 sets of 5 repetitions. Kadija et al. [32] evaluated isometrically and used 2 maximum isometric contractions sustained for 6 seconds. Other studies did not specify the repetitions performed [37, 40].

3.8 Included protocols quality assessment

The quality assessment of the included studies consisted of 14 high-quality studies and 9 medium-quality studies. Thus, 61% of the studies included in this review are of high quality and 39% are classified as medium quality.

Table 2
Quality assessment scale adapted to the isokinetic evaluation

Authors		1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	T’	T%	AT%
Herrington et al. [30]	As 1	2	2	2	2	2	2	1	0	2	0	2	2	2	2	0	2	2	2	2	2	33	82.5	85.0
	As 2	2	2	2	2	2	2	2	1	2	0	2	0	2	2	2	2	2	2	2	2	35	87.5
Milutinovic et al. [36]	As 1	2	1	2	2	2	0	2	2	2	0	0	2	2	0	1	2	2	2	2	2	30	75.0	71.2
	As 2	2	1	2	2	0	0	2	0	2	0	0	2	2	0	2	2	2	2	2	2	27	67.5
Akinci et al. [22]	As 1	2	2	2	2	0	0	2	0	2	0	0	0	2	2	2	2	2	1	2	2	27	67.5	68.7
	As 2	2	2	2	2	0	2	2	0	2	0	0	0	2	0	2	2	2	2	2	2	28	70.0
Carolan et al. [25]	As 1	2	2	2	2	2	0	2	0	2	0	2	1	2	1	2	2	2	2	2	2	32	80.0	82.5
	As 2	2	2	2	2	2	0	2	0	2	0	2	2	2	2	2	2	2	2	2	2	34	85.0
O’Connor et al. [38]	As 1	2	2	2	1	2	0	2	0	2	0	0	2	2	2	2	2	2	2	2	1	30	75.0	75.0
	As 2	2	2	2	1	2	0	2	0	2	0	0	2	2	2	2	2	2	2	2	1	30	75.0
Krzemińska et al. [33]	As 1	2	0	2	2	0	0	2	0	2	0	0	2	2	0	2	2	2	2	2	2	26	65.0	65.0
	As 2	2	0	2	2	0	0	2	0	2	0	0	2	2	0	2	2	2	2	2	2	26	65.0
Abellaneda et al. [21]	As 1	1	1	1	2	2	0	2	0	2	2	2	2	2	2	2	2	2	2	2	0	31	77.5	76.2
	As 2	1	1	1	1	2	0	2	0	2	2	2	2	2	2	2	2	2	2	2	0	30	75.0
Pelegrinelli et al. [40]	As 1	2	2	1	1	0	0	2	0	2	2	2	2	2	0	0	2	2	1	2	2	27	67.5	67.5
	As 2	2	2	1	0	0	0	2	0	2	2	2	2	2	0	2	2	2	1	1	2	27	67.5
O’Malley et al. [39]	As 1	2	2	2	2	2	0	2	0	2	0	0	2	2	0	2	2	2	2	2	2	30	75.0	75.0
	As 2	2	2	1	2	2	0	2	0	2	0	0	2	2	1	2	2	2	2	2	2	30	75.0
Seo et al. [41]	As 1	2	2	2	2	2	0	1	0	2	0	0	0	2	0	2	2	2	1	2	2	26	65.0	65.0
	As 2	2	2	2	2	2	0	1	0	2	0	0	0	2	0	2	2	2	2	1	2	26	65.0
Kadija et al. [32]	As 1	2	2	2	2	2	0	2	0	2	0	0	2	0	2	2	2	2	2	2	2	30	75.0	62.5
	As 2	2	2	2	2	0	0	0	0	2	0	0	0	0	0	0	2	2	2	2	2	20	50.0
Kyritsis et al. [34]	As 1	2	0	2	2	2	0	2	0	2	0	0	0	2	0	2	2	2	2	2	2	26	65.0	65.0
	As 2	2	0	2	2	2	0	2	0	2	0	0	0	2	0	2	2	2	2	2	2	26	65.0
Cvjetkovic et al. [26]	As 1	2	1	1	0	0	0	2	0	2	0	2	2	2	2	2	2	2	2	1	0	25	62.5	65.0
	As 2	2	2	1	0	0	0	2	0	2	0	2	2	2	2	2	2	2	2	2	0	27	67.5
Czaplicki et al. [27]	As 1	2	0	2	0	0	0	2	0	2	0	0	2	2	2	2	2	2	2	2	1	25	62.5	62.5
	As 2	2	0	2	0	2	0	2	0	2	0	2	2	2	0	2	2	2	2	2	1	25	62.5
Dagnoni et al. [28]	As 1	2	2	2	2	2	0	2	2	2	0	0	2	2	2	2	2	2	2	2	0	32	80.0	78.7
	As 2	2	2	1	2	2	0	2	2	2	0	0	2	2	2	2	2	2	2	2	0	31	77.5
Mohammadi et al. [37]	As 1	2	1	2	2	2	2	1	0	2	0	0	1	2	0	2	2	2	2	2	2	29	72.5	70.0
	As 2	2	0	2	2	2	0	1	0	2	0	0	2	2	0	2	2	2	2	2	2	27	67.5
Xergia et al. [43]	As 1	2	2	2	2	2	0	2	1	2	0	2	2	2	2	2	2	2	2	2	2	35	87.5	85.0
	As 2	2	2	2	2	1	0	2	0	2	0	2	2	2	2	2	2	2	2	2	2	33	82.5
Baltaci et al. [23]	As 1	2	0	2	0	2	0	1	0	2	0	0	1	2	0	0	2	2	1	2	0	19	47.5	47.5
	As 2	2	0	2	0	2	0	0	0	2	0	0	2	2	0	0	2	2	1	2	0	19	47.5
Thiele et al. [42]	As 1	2	0	2	0	0	0	2	0	2	0	0	2	2	1	0	2	2	1	0	0	18	45.0	47.5
	As 2	2	0	2	0	0	0	2	0	2	0	0	0	2	2	2	2	2	2	0	0	20	50.0
Dauty et al. [29]	As 1	2	1	2	2	1	0	2	1	2	0	0	2	2	2	2	2	2	2	2	0	29	72.5	73.7
	As 2	2	0	2	2	2	0	2	0	2	2	0	2	2	2	2	2	2	2	2	0	30	75.0
Lustosa et al. [35]	As 1	2	0	2	1	0	0	2	2	2	0	0	2	2	2	0	2	2	2	2	2	27	67.5	68.7
	As 2	2	0	2	1	0	0	2	0	2	2	0	2	2	2	1	2	2	2	2	2	28	70.0
Jamshidi et al. [31]	As 1	2	0	2	1	0	0	2	0	2	2	2	2	2	2	2	2	2	1	2	0	28	70.0	67.5
	As 2	2	0	2	0	0	0	2	0	2	2	2	2	2	2	2	2	2	0	2	0	26	65.0
Cardone et al. [24]	As 1	2	0	1	0	0	0	2	1	2	0	0	2	2	0	2	2	2	2	2	0	22	55.0	55.0
	As 2	2	0	2	0	0	0	2	0	2	0	0	2	2	0	2	2	2	2	2	0	22	55.0

As 1: Assessor 1; As 2: Assessor 2; T: total score; T%: Total score in percentage; AT%: Average total score in percentage.

The reliability values for the evaluation instrument adapted by the authors were calculated by means of each question of the form as follow: assessor 1 with assessor 2 $=$ 0.554 (0.008; 0.815), assessor 1 with assessor 3 $=$ 0.671 (0.058; 0.881) and assessor 2 with assessor 3 $=$ 0.814 (0.614; 0.917). The values and percentage of assessor 1 with assessor 2 are described in Table 2.

Table 3

Additional information about included studies

Year of study	Type of surgical procedure	Postoperative time for isokinetic evaluation	Fatigue during isokinetic assessment/functional tests	Functional tests/scales/questionnaires	Injury recurrence
Herrington et al. [30]	10 participants received hamstring tendon autograft 5 participants received patellar tendon autograft	Time since surgery 7.8 $\pm$ 1.3 months	The tests were performed with 10 minutes of rest between each group of tests, to minimize any effect of fatigue.	Hop tests: the assessment of single hop for distance and cross over hop for distance was performed. KOOS questionnaire	Not informed
Milutinovic et al. [36]	Not informed	End of 8th month and beginning of 9th month after ACL reconstruction	Not informed	Not informed	None of the soccer players had recurrent ACL injuries for an average of 2.5 years since starting the full training and competition process
Akinci et al. [22]	Autogenous hamstring tendon autograft	Participants were evaluated on average 33.26 $\pm$ 17.12 months after surgery	Not informed	Anterior Cruciate Ligament-Return to Sport After Injury Scale (ACL-RSI) Anterior Cruciate Ligament Quality of Life Questionnaire (ACL-QoL)	Not informed
Carolan et al. [25]	The choice of graft varied between bone-tendon-patellar bone (BPTB) and HS (gracilis/semitendinous dual bundle) in the P-ACLR group (252 BPTB, 46 HS) and BPTB, HS and QT in the R-ACLR group (22 BPTB, 17 HS, 7 QT). Extra-articular tenodesis with an iliotibial band was performed in a total of 11 cases (2 P-ACLR and 9 R-ACLR)	Participants were introduced to the facility for follow-up testing at 3, 6, and 9 months after surgery	Not informed	The explosive strength of the lower limbs was assessed by analyzing the jump height in the single leg countermovement jump (SLCMJ) Reactive strength was assessed using single leg drop jump (SLDJ) analysis	Not informed
O’Connor et al. [38]	All participants had patellar tendon or hamstring autograft (semitendinous or gracilis)	9 months (8.8 $\pm$ 0.7 months) after ACL reconstruction	Not informed	ACL-RS Questionnaire I; The jump testing took place on 2 force platforms (BP400600; AMTI) to capture ground-reaction forces at 1000 Hz	Not informed
Krzemińska et al. [33]	Participants were athletes after primary unilateral ACL reconstruction using tendons from the semitendinosus or semitendinosus and gracilis muscles, harvested from the operated leg	6 months after ACL reconstruction	Not informed	Prior to each isokinetic test, a 100 mm Visual Analogue Scale was used to assess pain intensity prior to measurement	Not informed

Table 3, contined
Year of study	Type of surgical procedure	Postoperative time for isokinetic evaluation	Fatigue during isokinetic assessment/functional tests	Functional tests/scales/questionnaires	Injury recurrence
Abellaneda et al. [21]	Not informed	Cohort 1, the 2 isokinetic tests were performed 3 and 6 months after the ACL reconstruction Cohort 2: the first isokinetic test was performed at the end of the second phase of rehabilitation, ie 12.9 $\pm$ 1 weeks after the ACL reconstruction. The second test was at the end of the fourth phase of rehabilitation, i.e., at 25.8 $\pm$ 1.6 weeks. In the case of cohort S2, the isokinetic tests was part of the regular functional tests set. When a patient could be evaluated, the evaluation was scheduled for one week and the isokinetic test was performed concurrently	Not informed	Measurements of passive range of motion, in knee flexion and extension; Test “Active Straight Leg Raise”; “Gait Cycle Analysis”, “Maintaining a 5s Single Leg Squat (Single Leg Squat 5s Hold Test)” tests; Test “Lateral Step Down”; Test “Bipodal Jump Landing Test”; For all jump tests (“Side Jump Test)”, “Single Leg Long Jump Test”, “Single Leg Triple Jump Test”, “Triple Crossing Test for Distance Test”, “T-velocity (T- test)”; KOOS and ACL-RSI questionnaires.	Not informed
Pelegrinelli et al. [40]	Dominant limb hamstring tendon autograft	4 to 6 months after surgery	Not informed	Not informed	Not informed
O’Malley et al. [39]	Primary ACL surgery with patellar tendon graft	Participants had undergone surgery an average of 6.6 $\pm$ 1.0 months before the test	Not informed	An 8-camera motion analysis system (200 Hz; model Bonita B10; Vicon Motion Systems, Hauppauge, NY), synchronized with two 40 $\times$ 60 cm force platforms (1000 Hz; model BP400600; Advanced Mechanical Technology Inc, Watertown , MA), was used to collect the kinematic and kinetic data of the single leg countermovement jump. Participants were instructed to stand with 1 foot on the force platform and the free leg back at approximately 90^∘. With their hands on the iliac crests, they were asked to complete a single leg countermovement jump, jumping as high as possible.	Not informed

Table 3, contined
Year of study	Type of surgical procedure	Postoperative time for isokinetic evaluation	Fatigue during isokinetic assessment/functional tests	Functional tests/scales/questionnaires	Injury recurrence
Seo et al. [41]	Autografts (bone-patellar tendon-bone vs semitendinosus and gracilis) were considered for inclusion	Participants before reconstruction and at 3, 6, and 12 months after (6 and 12 months for hop test) ACL reconstruction	Not informed	International Knee Documentation Committee (IKDC) Functional performance was measured through the hop test with one leg.	Not informed
Kadija et al. [32]	Autograft (bone-patellar tendon-bone)	4.0 $\pm$ 0.1 months after ACL reconstruction	Not informed	Questionnaires (subjective IKDC score and Tegner score) Knee laxity test performed with a KT1000 instrumented arthrometer at 13.61 kg of force.	Not informed
Kyritsis et al. [34]	5 surgeons were involved using two different surgical techniques: hamstring or bone grafts – patellar tendon – bone. Both techniques were standardized and a femoral tunnel via anteromedial portal was used for all	Not informed	During the isokinetic test, fatigue at work was investigated	Running T test; Single jump test; Triple jump test; Triple cross jump test	Athletes (N $=$ 158) returned to their previous competitive level on average 229 days after surgery (range 116 to 513 days). Of these, 26 (16.5% of 158) had ACL graft rupture and 11 (7.0% of 158) had contralateral native ACL rupture. Of the athletes who suffered an ACL graft rupture during the follow-up period, 17 (65.4% of 26) re-injured within the first 6 months after RTS. The median time from RTS to ACL graft rupture was 105 days. Of the 158 athletes, 141 (89%) were followed for at least 6 months and 112 (71%) for at least 12 months
Cvjetkovic et al. [26]	ACL reconstruction with hamstring tendon	Participants performed a rehabilitation protocol 6 months before the isokinetic test	Not informed	Not informed	Not informed
Czaplicki et al. [27]	Arthroscopic ACL reconstructions were completed using the anatomical single-bundle technique. Replacement material was four-thread tendon autografts.	Isokinetic assessment was measured at 4 stages: before surgery, 3, 6 and 12 months after reconstruction	Not informed	Not informed	Not informed

Table 3, contined
Year of study	Type of surgical procedure	Postoperative time for isokinetic evaluation	Fatigue during isokinetic assessment/functional tests	Functional tests/scales/questionnaires	Injury recurrence
Dagnoni et al. [28]	Semitendinosus graft	Isokinetic assessment performed 4-8 months after surgery	Not informed	Not informed	Not informed
Mohammadi et al. [37]	One group used a bone-patellar tendon-bone graft and the other group used a semitendinosus and gracilis tendon graft	Average of 8 months (range, 6 to 9 months) postoperative	Not informed	Hop Testing: long jump tests (single, triple and cross jump); 6 m timed jump test; Jump Landing: Participants were asked to drop from a 40 cm platform onto one limb on a 40 $\times$ 60 Kistler force platform, immediately jump as high as they could, then contact the force platform with the same limb again.	Not informed
Xergia et al. [43]	All participants had a single bone-patellar tendon autograft	6 to 9 months (mean, 7.01 $\pm$ 0.93 months) after surgery	Not informed	Tegner activity scale and the subjective form of the International Knee Documentation Committee (IKDC 2000) Single-limb hop test: performed until 3 successful hops are made with each limb. Each participant performed 3 training sessions and 3 real jumps for each limb. Testing started with the contralateral limb, followed by the reconstructed limb.	Not informed
Baltaci et al. [23]	Bone-tendon-patellar bone graft	Participants were evaluated at an average of 20 $\pm$ 3.1 months after ACL reconstruction	Not informed	Single leg jump test; Timed jump test 6m on one leg; Single leg triple jump test; Triple cross jump test; Vertical jump test; Shuttle run-1 test; Figure 8 run test; Side run test; Carioca test; Up/down stairs test Slope up/down test Step jump test; Participants completed the Hospital for Special Knee Score and activity scales from Lysholm and Tegner	Not informed
Thiele et al. [42]	Patellar tendon	Isokinetic assessment applied preoperatively and 4 months postoperatively	Not informed	Not informed	Not informed

Table 3, contined
Year of study	Type of surgical procedure	Postoperative time for isokinetic evaluation	Fatigue during isokinetic assessment/functional tests	Functional tests/scales/questionnaires	Injury recurrence
Dauty et al. [29]	Patellar tendon or hamstring technique	Isokinetic evaluations were performed on the 4th, 6th and 12th month after surgery	Not informed	Tegner (0 to 10) and Lysholm (0 to 100) scores were considered during follow-up at 4, 6 and 12 months postoperatively; The Association for Research and Promotion of the Study of the Knee (Arpège) score and the International Knee Documentation Committee score (IKDC 2000) were calculated at the 12th postoperative month; Single Legged Hop Test, measured at the 12th postoperative month; Laxity was evaluated using a tensile laxity meter (KT-1000^®, MEDmetric Corp. San Diego, USA).	Not informed
Lustosa et al. [35]	Patellar ligament graft	Average time of the adapted group 67.31 ( $\pm$ 28.52) months and non-adapted group 52.20 ( $\pm$ 31.33) months	Not informed	Cincinnati Knee Rating System Functional Scale; Evaluation of passive ligament laxity measurement performed with the KT-1000 arthrometer (Medmetric Corporation, San Diego, California); Hop test: single jump over a distance of one foot; Straight-line running test; Run in figure 8.	Not informed
Jamshidi et al. [31]	Patellar tendon graft	After 6 months of ACL reconstruction surgery	Not informed	Single leg jump test; Triple cross jump test; Vertical jump test; Participants completed the IKDC Subjective Knee Assessment Form.	Not informed
Cardone et al. [24]	Proximal tibial bone graft	2, 4 and 6 months postoperatively	Not informed	Clinical assessment of joint range of motion, effusion occurrence and stability assessment (Lachman, anterior drawer and “Pivot-shift” tests).	Not informed

ACL: anterior cruciate ligament; IKDC: International Knee Documentation Committee; ACL-RSI: Anterior Cruciate Ligament-Return to Sport After Injury Scale; SLDJ: Single leg drop jump; SLCMJ: Single leg countermovement jump; ACL-QoL: Anterior Cruciate Ligament Quality of Life Questionnaire; BPTB: bone- patellar tendon-bone; HS: gracilis/semitendinous double bundle; KOOS: Knee and Osteoarthritis Outcome Score; QT: quadriceps; P-ACLR: Primary anterior cruciate ligament reconstruction; R-ACLR: Revision of anterior cruciate ligament reconstruction.

3.9 Additional information about included studies

Additional information about the included studies, such as the type of surgical procedure, postoperative time, whether there was fatigue during the isokinetic evaluation, use of functional tests and recurrence of injuries, are shown in Table 3.

4. Discussion

The aim of this study was to verify the most used parameters during isokinetic evaluation for discharge after anterior cruciate ligament reconstruction. According to Fonseca et al. [48] isokinetic parameters have been used in research and clinical practice, providing accurate data on muscle performance and information on joint rebalance. The main results of this study indicate that the most used parameters correspond to the angular velocity of 60^∘/s, 1 set of 5 repetitions, concentric mode and variable peak moment. In addition, most studies performed warm-up and familiarization with the device before the evaluation.

4.1 Main findings interpretation

According to Dvir [49] isokinetic dynamometry is considered the gold standard due to the reliability in quantifying the variables related to muscle performance generated by muscle contraction. The most used contraction mode in the studies [21, 22, 24, 25, 26, 28, 30, 31, 34, 35, 37, 39, 40, 41, 42, 43]was the concentric mode. This choice can be justified by the fact of easy-to-understand execution, making muscle contraction more effective for evaluation. On the other hand, the eccentric mode is more complex, requiring greater motor control compared to the concentric mode and consequently more familiarization with the device. Thus, it can decrease the reliability and reproducibility of isokinetic evaluation [23].

The peak moment, measured in 21 studies [21, 22, 23, 24, 25, 26, 27, 29, 30, 31, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43]is the maximum force produced during the range of motion and the lower the dynamometer velocity, the higher the peak moment [12, 50, 51]. Thus, it is understood that it is preferable that the peak moment be evaluated at slow angular velocities, such as 60^∘/s, to potentiate muscle strength ability, which is in accordance with the results of the study in which the angular velocity of 60^∘/s was the most used. Roe et al. [15] evaluated muscle strength as a criterion for returning to sport in 82.5% of the studies, the isokinetic strength at 60^∘/s is the most used angular velocity, which corresponds to 33.3% of the included studies. Quadriceps weakness correlates with greater movement asymmetries, being predictive of failure in the criteria for returning to sport [15].

In the review by Burgi et al. [52] from the 209 studies included, 41% included strength as a criterion for returning to sport and 40% of the 50 studies that used isokinetic force as part of the return to sport criteria required a limb symmetry index with at least 85% [52]. This corroborates this study results, because the limb symmetry index was analyzed in 39% of the included studies. Bilateral deficit, i.e., strength deficit greater than 10%, may be a risk factor in knee injuries [15, 53, 54]. The isokinetic evaluation indicates muscle asymmetry and these values are fundamental due to the maintenance of symmetry between limbs [48] because the asymmetric strength of the quadriceps is directly proportional to the risk of new rupture of the anterior cruciate ligament [55, 56]. Thus, the bilateral deficit is an important variable to be considered as one of the discharge and return to sport criteria.

Although peak moment is the most commonly measured variable, H/Q ratio is a fundamental element to observe muscle movement efficiency and joint stability after anterior cruciate ligament reconstruction [57]. The H/Q ratio is calculated by the hamstring peak moment divided by the quadriceps peak moment [12, 51, 58]. This ratio is important as it will show the muscle imbalance resulting from the injury. At slow velocities, the H/Q ratio is around 60% for healthy individuals, values below 50% indicate severe muscle imbalance and may predispose to new injuries [58]. According to Dingenen and Gokeler [56] for every 10% reduction in the H/Q there is a greater risk of 10.6 times of a new rupture of the anterior cruciate ligament [56]. Thus, the H/Q ratio is a necessary and objective parameter for discharge and return to sport, establishing a more assertive decision in order to prevent injury recurrences.

Regarding the set and repetitions used during isokinetic evaluations, 10 studies performed 1 set of 5 repetitions [22, 23, 25, 26, 30, 33, 34, 35, 42, 43]. Baltaci et al. [23]. Cvjetkovic et al. [26] and Czaplicki et al. [27] used 1 set of 5 repetitions at 60^∘/s and 1 set of 10 repetitions at 180^∘/s. For the velocity of 60^∘/s, a few repetitions were performed, while for 180^∘/s a higher volume of repetitions was performed. It is recommended to perform fewer repetitions for peak moment evaluation at lower angular velocities, because peak moment presents an inverse relationship to the angular velocity applied to the test, in other words, the lower the velocity in the dynamometer, the higher the peak moment [12]. However, for power, a higher volume of repetitions is performed at higher velocities, because the power is higher in the velocity of movement in the shortest fraction of time [59]. Thus, it is essential to perform the evaluation at both velocities, because muscle strength (peak moment) and muscle velocity or explosion (power) are important components of muscle function, since power is widely used in sports gestures [60] and its evaluation for discharge and return to sport is fundamental.

4.2 Limitations

The major limitation of this study is that the criterion for selecting the final recommendations to perform knee isokinetic assessment after ACL reconstruction and rehabilitation to return to physical activities is based only on the frequency of findings. There are no evaluation quality criteria, nor comparison with other parameters such as functional tests, new ACL injury or fatigue during the test. Future studies with the purpose of comparing other parameters with isokinetic evaluation are suggested. It would also be informative and beneficial if there were descriptions of isokinetic assessment protocol modifications according to time since surgery.

There was difficulty in including all eligible studies, although the authors were contacted [44, 45, 46, 47]. In addition, it was not possible to perform a meta-analysis of the studies included in the review, due to the descriptive characteristic of the parameters used during the isokinetic evaluation at discharge after anterior cruciate ligament reconstruction. Another possible limitation, regarding the sample analyzed, the level of physical activity was not stratified, which may differ the isokinetic evaluation among active, sedentary or athletes. In addition, only male participants were included. Thus, the results of this study cannot be extrapolated to the general population.

Another limitation of the study was that only Jamshidi et al. [31] cited the Dynamic Control Ratio (Hecc/Qcon), described for the first time by Dvir et al. [61]. This ratio, which reflects the hamstring capacity to eccentrically the restrain forward movements of the tibia due to strong quadriceps concentric contraction was significantly higher in the ACL-deficient knee than in the healthy knee. Further studies are needed to investigate the relationship to high-level sports performance and return to sports after anterior cruciate ligament reconstruction.

4.3 Clinical implications

This systematic review presents the main conducts and evaluations for discharge and return to sport through the isokinetic dynamometer, what has been used and which variables are prioritized. The parameters identification during isokinetic evaluation will help to support clinical practice and scientific research, improving clinical accuracy on the method used for patients evaluation for physical therapy discharge.

The results show that the studies are focused on the evaluation of muscle strength as a criterion for discharge and return to sport. Other criteria should still be taken into account during evaluation, such as the evaluation of power, total work, H/Q ratio and bilateral deficit analysis. Changes in isokinetic parameters are related to injuries and to deficits evaluated [4]. There is little evidence in the literature on the muscular deficiency index (MDI) [62] which could be useful to establish functional progression and discharge criteria, through minimum values of symmetry between the limbs. Thus, primary studies are necessary to investigate its repercussions. In addition, other criteria such as the complementary use of other tests, for instance functional tests, are essential to complement the decision on discharge and return to sport, to investigate functionality in conjunction with muscle strength.

Future studies are needed to verify which are the most used isokinetic parameters during discharge for more specific population such as women, since the population may present differences, especially during muscle strength evaluation. Furthermore, to investigate in the literature whether there are differences in the isokinetic parameters used during the evaluation of patients after anterior cruciate ligament reconstruction and healthy population. It is suggested that future primary studies describe in detail the protocols used, and may be based according to Appendix 2 used in this study. It is recommended that the H/Q ratio and limb symmetry index be approached more intensely in clinical practice, as they are fundamental to observe the efficiency of muscle rebalance after anterior cruciate ligament reconstruction for discharge and return to sport.

5. Conclusion

The results of the present study indicate that the most used parameters during the isokinetic evaluation for discharge after anterior cruciate ligament reconstruction were: angular velocity of 60^∘/s, 1 set of 5 repetitions, concentric mode and variable peak moment. It is important to emphasize that the recommendations of this study are based only on the frequency of findings, and not on the frequency of new injuries or other qualitative criteria.

Author contributions

All authors contributed to the conception, design, analysis and results interpretation. All authors contributed to the manuscript writing and critical review.

Data sharing

All data relevant to the study are included in the manuscript or appendices.

Ethical considerations

There was no patient or public involvement in this study.

PROSPERO register

Isokinetic parameters used during discharge in patients after ACL reconstruction rehabilitation: a systematic review. ID: CRD42021224433.

Footnotes

Acknowledgments

To the Araucaria Foundation for Scientific and Technological Support and Development. Ana Carolina de Jacomo Claudio was a fellow of the Institutional Program of Scientific Initiation Scholarships (PIBIC), having financial support from the Araucaria Foundation for Scientific and Technological Support and Development.

Conflict of interest

The authors declare that there are no conflicts of interest.

Appendix 1. Search strategies description in each database

Appendix 2. Customized checklist adapted for the Isokinetic Dynamometer

Have the research objectives or goals been clearly stated?

Has the study design been clearly described?

Has the study population been adequately described?

Have the eligibility criteria been specified?

Has the sampling methodology been adequately described?

Was the sample size used justified?

Has the description of the method allowed precise replication of measurement procedures?

Has the participants evaluator been described (e.g., experience)?

Has a system been reported to standardize motion instructions? (yes)

10.

Has the isokinetic been calibrated?

11.

Was there a gravity correction?

12.

Was warm-up performed?

13.

Have the angular velocities analyzed been clearly described?

14.

Has familiarization been performed?

15.

Have the measured variables been clearly described?

16.

Has the system been compared to a recognized gold standard? (yes)

17.

Have reliability/accuracy measurements of the equipment used been reported? (yes)

18.

Have the main findings of the study been declared?

19.

Were the statistical tests appropriate?

20.

Have the limitations of the study been clearly described?

Each item was evaluated with 0 points when not described, 1 point when considered limited description and 2 points when adequately described.

The total score was calculated and the studies were classified as low quality (score $<$ 33.3%), average quality (score between 33.4–66.7%) or high quality (score $>$ 66.8%).

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Isokinetic testing protocol-based discharge criteria after anterior ligament reconstruction: A systematic review

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULT:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Search strategy

2.2 Inclusion and exclusion criteria

2.3 Studies selection

2.4 Data extraction

2.6 Data analysis

3. Results

3.1 Studies inclusion

3.2 Studies characteristics

Table 1 Description of the studies included in the analysis

3.4 Contraction mode

3.5 Angular velocities

3.6 Isokinetic variables

3.7 Sets and repetitions

3.8 Included protocols quality assessment

Table 2 Quality assessment scale adapted to the isokinetic evaluation

4. Discussion

4.1 Main findings interpretation

4.2 Limitations

4.3 Clinical implications

5. Conclusion

Author contributions

Data sharing

Ethical considerations

PROSPERO register

Footnotes

Acknowledgments

Conflict of interest

Appendix 1. Search strategies description in each database

Appendix 2. Customized checklist adapted for the Isokinetic Dynamometer

References

Table 1
Description of the studies included in the analysis

Table 2
Quality assessment scale adapted to the isokinetic evaluation