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Knee Surg Sports Traumatol Arthrosc

(2004) 12 : 350–356 KNEE


DOI 10.1007/s00167-004-0518-4

Jesper Augustsson Ability of a new hop test


Roland Thomeé
Jon Karlsson to determine functional deficits
after anterior cruciate
ligament reconstruction

Received: 21 August 2003


Abstract The aim of this study was tion. Sixty-three per cent exhibited
Accepted: 19 February 2004 to investigate the ability of a new hop 1 RM strength scores of below 90%
Published online: 8 May 2004 test to determine functional deficits of the non-involved leg. Eighty-four
© Springer-Verlag 2004 after anterior cruciate ligament (ACL) percent of the patients exhibited ab-
reconstruction. The test consists of normal symmetry in at least one of
a pre-exhaustion exercise protocol the tests. Our findings indicate that
combined with a single-leg hop. patients are not fully rehabilitated
Nineteen male patients with ACL re- 11 months after ACL reconstruction.
construction (mean time after opera- It is concluded that the pre-exhaus-
tion 11 months) who exhibited nor- tion exercise protocol, combined
mal single-leg hop symmetry values with the single-leg hop test, im-
J. Augustsson (✉) · R. Thomeé · (≥90% compared with the non-in- proved testing sensitivity when eval-
J. Karlsson volved extremity) were tested for uating lower-extremity function after
Lundberg Laboratory one-repetition maximum (1 RM) ACL reconstruction. For a more
for Human Muscle Function strength of a knee-extension exer- comprehensive evaluation of lower-
and Movement Analysis,
Department of Orthopaedics, cise. The patients then performed extremity function after ACL recon-
Sahlgrenska University Hospital, single-leg hops following a standard- struction, it is therefore suggested
Göteborg University, ised pre-exhaustion exercise proto- that functional testing should be per-
413 45 Göteborg, Sweden col, which consisted of unilateral formed both under non-fatigued and
Tel.: +46-31-426891,
Fax: +46-31-416816, weight machine knee-extensions un- fatigued test conditions.
e-mail: jesper.augustsson@orthop.gu.se til failure at 50% of 1 RM. Although
no patients displayed abnormal hop Keywords Anterior cruciate
J. Augustsson
Department of Rehabilitation Medicine, symmetry when non-fatigued, 68% ligament · Knee · Rehabilitation ·
Sahlgrenska University Hospital, of the patients showed abnormal hop Muscle fatigue · Exercise test
Göteborg University, Göteborg, Sweden symmetry for the fatigued test condi-

in detecting functional limitations in ACL-deficient knees


Introduction was relatively low [23, 29]. To improve the sensitivity of
tests of lower-extremity function in evaluating the effect
Injuries often tend to occur at the end of a sporting event, of rehabilitation interventions, the testing of dynamic
when a participant is fatigued [10, 12, 35]. However, it function under fatigued conditions has been suggested
has been our observation that current functional tests, [6]. We have previously developed, and examined the re-
such as the single-leg hop, are typically performed under liability of a single-leg hop test performed under standard-
non-fatigued test conditions both in the clinical and scien- ised, fatigued conditions in healthy subjects. The results
tific setting. The ability of these tests to assess whether a of this work showed high test-retest reliability for the
patient has regained lower-extremity function after ante- fatigued hop-test condition (J. Augustsson et al., submit-
rior cruciate ligament (ACL) reconstruction, for example, ted). We hypothesised that performing single-leg hop test-
could therefore be regarded as limited. In accordance with ing under conditions of fatigue may be more sensitive in
this, the reported sensitivity of several types of hop tests detecting functional impairment after ACL reconstruc-
351

tion, when compared with traditional, non-fatigued hop termined again in a test-retest design. The hop test was
testing. then performed under fatigued conditions (see below for
The purpose of this study was to investigate the ability test procedure) for familiarisation purposes. At the third
of a new hop test to determine functional deficits after session, patients performed the hop test under non-fa-
ACL reconstruction. tigued and fatigued test conditions.
All the strength and functional tests were conducted in
a blinded fashion, as patients concealed their knees by
Materials and methods wearing elastic wraps. In this way, the test leader (J.A.)
did not know whether the involved or the non-involved
Patients leg was being tested during a particular test session.

Nineteen male patients with a unilateral ACL injury who


had undergone ACL reconstruction were recruited for this Pre-test procedures
study in a consecutive manner from a cohort of patients
that had undergone reconstruction of the ACL at Sahl- When performing the single-leg hop test, the patient was
grenska University Hospital, Östra, Sweden. The inclu- instructed to stand on one leg and to position his toes to a
sion criteria included there being no other or subsequent mark on the floor. The patient was then instructed to hop
injuries to the surgical limb, and no injury to the unin- forward as far as possible and to land on the same leg. The
volved knee, hips, ankles or back. Further inclusion crite- patient was instructed to hold his hands on his hips
ria were at least six months of post-operative physical throughout the jump. The distance, in centimetres, was
therapy, a single-leg hop symmetry index of ≥90%, age measured from the toe in the starting position to the heel
between 20 and 35 years, male gender and pain intensity where the patient landed. A hop was only regarded as suc-
of less than five on a 10–cm visual analogue scale (VAS) cessful if the patient was able to keep his foot in place af-
on the day of the examination. Clinical knee-joint exami- ter landing (i.e., no extra hops for balance correction were
nation, performed on both of the patients’ knees by an ex- allowed) until the investigator had marked where the pa-
perienced physical therapist (R.T.), revealed no signs of tient landed. The test was performed until three successful
increased laxity (using the Lachman test), swelling, joint hops were made with each leg, with the starting order of
line tenderness or decreased range of motion. the right or the left leg randomly assigned to the patients.
The descriptive data of the patients was mean (±SD) For the non-fatigued condition, each patient was given
age, body weight and height of 28±5 years, 79±8 kg and two practice trials before the test.
182±5 cm respectively. Mean (±SD) time since surgery Each patient’s unilateral 1 RM for the involved and the
was 11±2 months, whereas the mean time (±SD) between uninvolved leg was determined for a knee-extension exer-
the index injury and reconstruction was 22±17 months. All cise by using the maximum weight that could be lifted for
the patients were at least recreational athletes and 69% one repetition. Patients were placed in a variable-resis-
(13/19) had returned to their previous level of sports par- tance knee-extension machine (Model Leg Extension FL
ticipation. In 16 cases, the ruptured ACL was reconstructed 130, Competition Line, Borås, Sweden). Each patient was
with a patellar tendon autograft, whereas a hamstring-ten- instructed in the proper technique for the exercise by the
don autograft was used in three cases. In ten cases, the test leader. The patients performed two sub-maximal
right leg was the injured leg, whilst in nine cases the left warm-up sets of the knee-extension exercise. The starting
leg was the injured leg. Eleven patients had an isolated and ending positions for the knee-extension exercise were
rupture of the ACL, seven patients had ruptures of the lat- seated with a knee flexion angle of approximately 90°.
eral meniscus and one patient had a rupture of the medial From the starting position, each patient extended his knee
meniscus. The study was approved by the Human Ethics and returned to the starting position. The pad supporting
Committee at the Faculty of Medicine, Göteborg Univer- the back was adjusted so that the axis of the knee joint
sity, Sweden. Informed written consent was obtained and was aligned with the axis of the resistance arm. The foot-
the rights of patients were protected. pad was positioned approximately 5 cm proximal to the
lateral malleolus. The weight lifted for each trial was in-
cremented by 2.5–10 kg until failure occurred. One minute
Research design of rest was allowed between trials. The starting order of
the right or the left leg was randomly assigned to patients.
Each patient performed three testing sessions, with at least A strength [26] and hop [19] symmetry index of ≥90%
7 days between sessions. At the first session, a hop test (involved versus non-involved side) was considered to be
under non-fatigued conditions was performed for famil- within normal ranges.
iarisation purposes and in addition knee-extension one-
repetition maximum (1 RM) strength was determined. At
the second session, knee-extension 1 RM strength was de-
352

1 RM, for example, quadriceps 1 RM strength is conse-


quently reduced by 50%.
Each patient began testing by performing single-leg
hops for the involved and uninvolved limb under non-
fatigued conditions, as previously described. The patients
then performed unilateral fatiguing knee-extensions until
failure occurred at 50% of their respective 1 RM, using a
variable-resistance knee-extension machine, followed im-
mediately by single-leg hops. The leg tested first was ran-
domised in each patient.
Each patient’s knee-flexing and knee-extending cadence
was not fixed during the knee-extension exercise; instead,
each patient was allowed to establish a “groove”, i.e. use
a self-selected cadence. The best hop performance for the
two test conditions was recorded. The number of hop tri-
als needed to make three successful hops for the different
test conditions was documented, as well as the number of
knee-extension repetitions performed at 50% of 1 RM.
Verbal encouragement and instructions were standard-
ised. Before both the pre-test and the testing sessions,
each patient performed a warm-up consisting of 10 min of
ergometer cycling at 70 rpm at a sub-maximal work level,
followed by 15 squats and 20 repetitions of toe raises. All
the patients wore the same type of athletic shoes during all
the sessions.

Fig. 1 Testing set-up: the patients performed unilateral pre-ex-


haustion exercise of the quadriceps muscle until failure using a Power analysis
variable-resistance knee-extension machine at a load of 50% of
1 RM, followed by a single-leg hop Based on a hypothesised 5–10% difference in perfor-
mance between hop-test conditions using the involved
and non-involved leg, the number of patients required to
Experimental protocol achieve a power of 0.90 was estimated by power analysis.

The hop performance was compared in two standardised


test conditions: (1) non-fatigued, and (2) immediately fol- Statistical methods
lowing pre-exhaustion exercise of the quadriceps muscle
at 50% of 1 RM strength (Fig. 1). In order to standardise The intraclass correlation (ICC) coefficient was computed
the fatiguing exercise, we used a fatigue protocol devel- for analyses of the test-retest reliability of the 1 RM test,
oped from previous work on healthy subjects [5], (J. Au- according to Shrout and Fleiss [27]. Differences in perfor-
gustsson et al., submitted). This fatigue protocol consists mance between fatigued and non-fatigued hop-test condi-
of a so-called “pre-exhaustion exercise”, which involves tions for the involved and the non-involved side, and dif-
working a muscle to fatigue by performing as many repe- ferences between the number of hop trials and knee-ex-
titions as possible in a single set at a load of, for example, tension repetitions, were analysed using paired t-tests.
50% of 1 RM, using a single-joint exercise; this exercise The significance was considered at the α level of p<0.05.
is immediately followed by a multijoint exercise. By adopt-
ing the concept of pre-exhaustion exercise, and by using
the RM continuum, we have constructed a testing proto- Results
col that quantifies both the level and the progression of
muscle fatigue. Hop and strength-testing symmetry
Specifically, a “target force” of pre-exhaustion activa-
tions can be set at a given percentage of 1 RM strength Because normal hop symmetry was required to be in-
(for example, 50% of 1 RM) and in turn allow for any de- cluded in this study, all the patients had hop-index values
gree of muscle fatigue to be obtained in a controlled man- above or equal to 90% for the hop test performed under
ner. So, if a subject performs as many repetitions as possi- non-fatigued conditions. However, 68% of the patients
ble of a knee-extension exercise until failure at 50% of (13/19) demonstrated abnormal hop symmetry under fa-
353

exhaustion exercise of the quadriceps muscle at 50% of


1 RM for the involved and the non-involved side was 5.0
(range 3–9) and 4.4 (range 3–7) respectively, with no sig-
nificant difference between sides (p=0.08).
No patients included in the study experienced pain ac-
cording to the VAS at the day of the examination.

Test–retest reliability for the 1-RM test

When analysing test-retest reliability for the 1-RM knee-


extension test we found excellent ICC [27] values – 0.96 –
for both the involved and the non-involved leg.

Discussion
Fig. 2 Results of the tests of functional ability and 1 RM knee-
extension strength. Values shown are percentages of patients after In addition to the single-leg hop test, which is the most
ACL reconstruction within the normal range [19, 26] commonly used test in current practice to assess knee func-
tion following ACL reconstruction [14, 25], we developed
tigued conditions (following pre-exhaustion of the quadri- a new test in which hop performance was investigated dur-
ceps at 50% of 1 RM) when testing their ACL-reconstructed ing conditions of fatigue. We hypothesised that this
leg. The percentage of patients with abnormal 1 RM knee- method would improve the possibility to evaluate the ef-
extension strength scores was 63% (12/19). Eighty-four fects of rehabilitation interventions. We found that patients
percent of the patients (16/19) exhibited abnormal sym- with normal single-leg hop ability achieved poorer results
metry in at least one of the tests (Fig. 2). using the involved leg when performing single-leg hops in
A summary of the results of the hop and strength tests a fatigued state. The functional disability after ACL recon-
is shown in Table 1. “Sensitivity” expresses the percent- struction could therefore be better delineated by the com-
age of patients with ACL reconstruction who showed ab- bination of pre-exhaustion exercise followed by a single-
normal lower-limb symmetry values in the tests. Taken to- leg hop test, rather than by a single-leg hop test alone. The
gether, the sensitivity level was 0% for the non-fatigued higher sensitivity of the combined pre-exhaustion exercise
hop test, 68% for the hop test performed under fatigued protocol and single-leg hop test may be explained by its
conditions, 63% for the 1 RM strength test, and 84% if we more-demanding, and thus more-discriminating nature
defined the patients as abnormal when at least one of the when compared with non-fatigued hop testing.
three tests showed an abnormal value. There are several possible reasons for the fact that,
The mean number (±SD) of repetitions of knee-exten- when fatigued, patients performed worse using the in-
sions until failure at 50% of 1 RM was not significantly volved leg during single-leg hop testing. Firstly, several
different for the involved and the non-involved leg (22± studies, including this one, have demonstrated that indi-
4 repetitions vs 21±3 repetitions, p=0.49). The mean num- viduals with ACL injury or reconstruction scored within a
ber of hop trials needed to obtain three successful hops for normal range during single-leg hop tests, yet showed re-
the involved and the non-involved side under non-fa- duced quadriceps strength [7, 11, 31]. It has been sug-
tigued test conditions was 5.0 (range 3–7) and 5.7 (range gested that this is due to the hip and ankle extensors being
3–8) respectively, with no significant difference between capable of compensating for a knee-extension moment
sides (p=0.08). The number of hop trials following pre- deficit in the involved extremity [11]. However, it is pos-

Table 1 Comparisons of single-leg hop performance under different test conditions and 1 RM knee-extension strength
Test difference Involved Non-involved Hop or strength Percentage
side side index between sides
Non-fatigued hop condition (cm) 141±21 145±22a 97±5c 3
Fatigued hop condition (cm) 109±21 121±21b 89±8 11
1 RM strength (kg) 53±8 62±11b 86±9 14
aDifferent from involved side, p<0.05
bDifferent from involved side, p<0.01
cDifferent from fatigued hop index, p<0.01
354

sible that, during the fatigued-hop conditions in our study, (p<0.01). In accordance with this, persistent quadriceps
the hip and ankle extensors were not able fully to com- weakness seems to be common in the ACL-reconstructed
pensate for the distinct quadriceps-strength deficit of the leg despite “aggressive” rehabilitation [2, 3, 8, 11, 16, 20,
involved leg. 22, 24, 30, 34]. In a recent study, Carter and Edinger [8]
Another possible reason for patients performing worse were intrigued to find that only half of the competitive
using the involved leg during fatigued single-leg hop test- athletes in their study had accomplished 80% or greater
ing is that the knee joint provides the major energy-ab- leg strength of the ACL-operated leg by 6 months after
sorption function during the landing phase of the single- surgery, as it is customary to allow return to full activities
leg hop (J. Augustsson et al., submitted). We observed that at that time, with some authors advocating return to sports
absorbed power was two to three times greater for the knee as early as 4 months after the procedure [9, 17]. In our
than for the hip, and five to ten times greater for the knee study, 63% of the patients had residual quadriceps-muscle
than for the ankle during landing in both fatigued and non- weakness 11 months after surgery, yet 69% had returned
fatigued test conditions in healthy subjects (J. Augustsson to their previous level of sports participation. We con-
et al., submitted). The task of landing during the fatigued- clude that patients may return to sports 11 months postop-
hop condition, using the involved leg, therefore presum- eratively, but that leg strength is frequently not adequate
ably led to great difficulties, on both a central and a pe- at that time to do so without running the risk of re-injur-
ripheral level, for the patients after ACL reconstruction. ing the knee.
In order to assess whether a safe return to sports or We used the 1-RM test to compare the knee-extension
strenuous work is possible following ACL reconstruction, strength of the involved and the non-involved side and
the ability to perform functional tests of the lower extrem- found excellent test-retest reliability (the ICC value was
ity within normal values is regarded as an important crite- 0.96 for the involved and the non-involved side). This is
rion [14]. Currently, however, there is no clear consensus in accordance with the results of Hennessy and Watson
with regard to the definition of normal range in functional [15], who noted high reliability for the 1-RM test for the
tests. For example, no single standard symmetry index is bench press and the barbell squat exercise (r=0.96 and
used for determining normal or abnormal maximal hop- 0.97 respectively) in healthy subjects. Although the iso-
test ability in knee rehabilitation. A ratio of limb symme- tonic 1-RM test is the most frequently-used tool for the
try known as the limb symmetry index (LSI) has been the evaluation of muscle strength in sports [21], strength in
most frequently reported criterion for assessing whether a knee rehabilitation is almost always evaluated with iso-
hop test is normal or abnormal [1]. The LSI is used to cal- kinetic dynamometry [2, 3, 7, 8, 9, 16, 20, 23, 24, 31, 34].
culate the difference in hop length between the injured and However, according to several studies [4, 28, 33], isoki-
uninjured sides. An LSI of 15% – i.e. a 15% difference netic tests are not sensitive to isotonic weight-training
between limbs – is often regarded as satisfactory for sin- strength improvements. The rationale for performing iso-
gle-leg hop tests [7]. However, it should be noted that kinetic tests in clinical practice is therefore somewhat
these values were empirically established by noting that weak, as weight training during rehabilitation is typically
90% of subjects without a history of ACL injury had LSIs performed using free weights and weight machines in an
greater than or equal to 85% [7]. Juris et al. [19] on the isotonic mode only.
other hand, noted hop-symmetry scores of 90% for the The movement velocity during the exhaustive knee-ex-
single-leg hop test in healthy subjects. Moreover, it has tension exercise set was not controlled in our study. This
been reported that in individuals with ACL-deficient knees is due to the fact that the cadence consistently decreases
only those performing at more than 90% of knee function from the first to the last repetition for a subject during a
(including the single-leg hop test) compared with the un- set of heavy weight-training exercise [18].
injured side were able successfully to return to pre-injury
levels of activity [13]. Although the degree of difference
in performance between the two lower extremities has not Conclusion
been shown to have a definite relationship with a propen-
sity towards injury during athletic activities [32], a differ- Although injuries tend to occur more frequently at the end
ence of 10% or more can be considered to reflect a real of a sporting event, when a participant is fatigued [10, 12,
difference in the capacity of performance [26]. Taken to- 35], patients are typically examined for return to sports
gether, we regard a side-to-side difference of more than using functional tests performed under non-fatigued con-
10% between the involved and non-involved leg follow- ditions. This may compromise the therapist’s ability to de-
ing ACL reconstruction as unsatisfactory for both hop- cide whether a patient with ACL reconstruction can safely
and strength-test scores, and believe that it may predis- return to sports or strenuous work activities. In accordance
pose a patient to overuse and/or acute injuries when re- with this, no patients in our study displayed abnormal hop
turning to sports or strenuous work. symmetry when non-fatigued; however, two-thirds showed
In our study, patients with ACL reconstruction exhib- abnormal hop symmetry for the fatigued test condition. It
ited a significant knee-extension 1-RM strength deficit is concluded that the pre-exhaustion exercise protocol
355

combined with the single-leg hop test improved testing Acknowledgements This study was supported by a grant from
sensitivity when evaluating lower-extremity function after the Swedish National Centre for Research in Sports. We declare
that the experiments performed in our study comply with the laws
ACL reconstruction. For a more realistic approach, when of Sweden.
it comes to the functional performance testing of patients
after ACL reconstruction it is suggested that these tests
should be performed both under non-fatigued and fa-
tigued test conditions.

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