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Sarah Weatherford
EDRM 600
Abstract
An injury to the anterior cruciate ligament (ACL) within the knee is thought to have a
negative impact on joint proprioception, even after the extensive rehabilitation process is
complete. The purpose of this research was to determine if there is a deficit in proprioception
study research method, twenty-six current and former Colorado State University student-
athletes were chosen for this study. Each of these participants was chosen due to the fact that
they had one or more previous ACL tear in one knee. At the time this data was collected, they
ranged in age from 17 23, although their age at the time of their ACL tear ranged from 13 to 20.
The participants’ time from reconstruction to when this data was collaged ranged from six years
to nine months. SWAY Balance was used as a method to measure proprioception through single
leg balance. Results of the study showed no significant difference between single leg balance
Area of Focus
Tears of the anterior cruciate ligament (ACL) are some of the most traumatic for an
athlete, given the recovery time and perceptions that their mechanics are forever changed.
During four years competing at the collegiate level, 3.2% of male athletes and 3.5% of female
athletes will tear their ACL at least once. Given the fact that the recovery process for this injury
is at least six months long, it is important that the rehabilitation process be taken seriously.
Mechanoreptors within the knee can both affect and be affected by injuries to the joint.
In terms of the ACL, these mechanoreceptors play a protective role and initiate a reflex that
stabilizes the knee to prevent injury. When the knee is injured, so are the mechanoreceptors,
which ultimately leads to a decrease in proprioception at the joint (Reider et al, 2003).
Proprioception is a necessary, functional sensory sensation that allows for proper joint
functionality (Lephart et al, 1992). Whether in the knee, shoulder, ankle, or any other joint,
Previous research has shown that what athletes perceive as a "successful" ACL
reconstruction correlates more with restored proprioception instead of stability of the graft
(Reider et al, 2003). If this is truly the case, it is important to place more emphasis on
athletes need to feel comfortable with their knee before returning to sports.
Purpose Statement: The purpose of this research is to investigate the relationship between
Research Question: Does tearing the ACL predispose an individual to lasting proprioception
deficits, even after the ligament is repaired? If so, what can the athlete do to decrease, and
The anterior cruciate ligament (ACL) makes up about 50% of all ligament injuries within
athletics (Bonfim et al, 2003). Surgery is almost always needed to repair the ligament, especially
if it is completely torn. Anatomical changes are well known post-reconstruction, but the
functional changes are only now beginning to be researched. Although physicians will base
return-to-play decisions on the stability of the knee joint post-anterior cruciate ligament (ACL)
The main purpose of the anterior cruciate ligament (ACL) is to prevent any “excessive
anterior tibial translation in various degrees of flexion” (Dhillon et al, 2011, p. 296). Research
has shown that it may take as few as 1725 Newtons of force to completely tear the ACL (Dhillon
et al, 2011), although that number may increase or decrease due to age, physical activity,
muscle strength, or any other number of factors. Loads on the knee joint can quickly exceed
this estimate during strenuous activities. During physical activity, the knee cannot rely simply
on the strength of the ligaments to maintain stability. The muscle contractions must be aided
by the sensations transmitted through mechanoreceptors in the ligaments to the brain (Dhillon
et al, 2011).
Proprioception Post-Anterior Cruciate Ligament Reconstruction 5
Proprioception is a specific sense of touch that combines joint movement and joint
positioning that has three components: static awareness of joint position, detection of
movement and acceleration, and efferent activity that starts reflex responses and regulates
muscle activity (Dhillon et al, 2011). There are two types of proprioception – conscious and
proprioception initiates reflex stabilization (Lephart et al, 1992). Mechanoreceptors are the
sensory cells that respond to touch stimuli, and are closely related to proprioception. Studies
have shown that there are a significant number of mechanoreceptors within the ACL; these
mechanoreceptors play a protective role for the ACL. When the mechanoreceptors are excited
by activity, they initiate a reflex that then leads to stabilizing contractions of the surrounding
muscles (Reider et al, 2003). Because the proprioception of the knee is compromised, the brain
interprets that feedback as saying that the mechanical stability of the knee is also
are damaged.
It is important to understand any proprioception deficits that occur within the knee joint
as the result of injury to the ACL because of lasting effects on the athlete. Studies have shown
that in knees with damage to the ACL, even after reconstruction of the ligament, there are
altered gait patterns, generally due to the change in proprioceptive feedback at the joint, not
any mechanical instability (Dhillon et al, 2011). Rehabilitation post-reconstruction of the ACL is
a lengthy process, a minimum of six months, but generally between nine and twelve months of
rehabilitation is needed before the athlete can be cleared for full return to activity. Research
Proprioception Post-Anterior Cruciate Ligament Reconstruction 6
has shown that an athlete’s perception of a successful surgery correlates more with “restored
Research Methods
This study consists of 26 current and former Colorado State University student-athletes
ages 18-23, with a previous history of anterior cruciate ligament (ACL) tears. Each of these
athletes has been cleared to fully participate in sports following six to twelve months of
rigorous rehabilitation. Individuals were excluded from this study if they had bilateral ACL tears
or any history of knee surgeries on the knee opposite of their ACL tear. The participants’ time
from reconstruction to when this data was collaged ranged from six years to nine months.
The SWAY Balance System is a mobile phone application used to assess sway as an
indicator of balance. While generally used to test an individual’s balance after sustaining a
concussion, it can also be used to look at proprioception bilaterally. When used for testing an
individual, it measures double leg balance, single leg balance on both legs, and tandem stance
balance on both legs; each test is performed with the individual's eyes closed. Scores are
calculated out of 100, with a higher score indicating better balance as a measure of
proprioception. See Figures 1-5 for visual explanations of how the SWAY Balance test is
completed.
Proprioception Post-Anterior Cruciate Ligament Reconstruction 7
Figure 1. SWAY Balance Figure 2. Double Leg Stance Figure 3. Tandem Stance
Participants in this study performed the SWAY Balance Assessment just as they would if
they were performing the test as a concussion screening tool. The test was performed on a
laminate floor, with the participants barefoot. The environment was quiet, allowing the
participants to focus on their balance and body awareness. All five tests were performed:
double leg stance, single leg stance bilaterally, and tandem stance bilaterally. Scores were
Participants completed the SWAY Balance test a total of three times, giving them three
measurements for double leg stance, tandem stance with left leg forward, tandem stance with
right leg forward, single leg stance on left foot, and single leg stance on right foot. Only data for
the single leg stances of the left and right leg were used for this research, due to the ability to
For data analysis, the participants’ three trials for the single leg stance on the left leg
and their three trials for the single leg stance on the right leg were averaged to get two
numbers for each student-athlete – one average for the leg with the previous ACL and
subsequent reconstruction, and another average for the healthy leg. The healthy leg served as
When gathering data, it was necessary to know whether the left or right knee of the
participant was previously injured. For analysis, however, the data was compiled into “Injured”
and “Uninjured” instead of “Left” and “Right”, as the side of injury was not being studied in this
research. A paired t test was used to analyze the data of the injured and uninjured single leg
balance scores.
Proprioception Post-Anterior Cruciate Ligament Reconstruction 9
Results
There were an equal number of males and females that participated in this research
study (Table 1), with eleven football players reporting a previous ACL tear (see Table 2), the
most of any varsity sport at Colorado State University. Track and field had six student-athletes
meet the inclusion criteria for this study – two males and four females. Cheer and dance and
women’s basketball followed with three student-athletes, then women’s soccer with two, and
There was a slight difference in the single leg balance score means of the two groups,
with injured having a lower score than uninjured by 2.3 percentage points, although this
difference was not significant. The P value of a one-tail t test was 0.0985, while the P value of a
two-tail t test was 0.197. The critical t value for a one-tail test was 1.708, while the critical t
value for a two-tail test was 2.060 (see Table 4). These results are not significant under the
The data has a Pearson Correlation Efficient of 0.745 (see Table 4), which shows a
positive correlation between the single leg stance balance scores of the injured and uninjured
sides.
Discussion
Proprioception is a key sensation in the human body that is necessary for body and
movement awareness. Without it, sports, activities of daily living, occupational tasks, and even
muscle function and reflex stabilization can be compromised or made to be extremely difficult
(Lephart et al, 1992). While previous researchers have used the threshold to detection of
passive motion (TTDPM or TDPM) to measure for any proprioception deficits, this research was
the first to use balance as a measure of proprioception. Previous research has found significant
differences in TTDPM between ACL reconstructed knees and the uninvolved knee (Lephart et al,
1992). While this research did find a difference in the mean balance scores between injured
although in a less controlled environment. Single leg balance is one of many other ways to
determine the proprioceptive feedback of a joint. The single leg balance test brings in more
Proprioception Post-Anterior Cruciate Ligament Reconstruction 12
variables for which to be accountable, such as the ankle and hip joints. This research did not
exclude participants with a history of hip, ankle, foot, or other lower extremity injuries, which
brings up a significant limitation of the study. Injuries to any joint in the body will cause a
decrease in proprioceptive feedback at the joint if it is not properly rehabilitated. SWAY Balance
results could very easily be affected if the participant had any number of injuries to the lower
represented than other sports; football players made up 42% (11 of 26) of all participants in this
study. While football is one of the sports with the highest rates of ACL tears in athletics,
women’s soccer has been widely shown to have the highest rate of ACL tears (Joseph et al,
2013). Women’s soccer only made up 7.7% (2 out of 26) of the participants in this study, which
can be explained by the fact that there are significantly fewer women’s soccer players in a
single NCAA Division 1 athletics program than there are football players. Football rosters
generally have anywhere from 100 to 140 males on their teams, while women’s soccer rosters
are usually capped around 30. These roster numbers explain why there are a higher number of
Other limitations of this research come from the small sample size of participants. With
only 26 participants, it is hard to generalize data results to the general population. Additionally,
all of the participants are also NCAA Division 1 athletes in their respective sports, but the ACL
tears they sustained occurred before they came to the collegiate level. This leads the
researcher to conclude that their rehabilitation protocol was outstanding and they were highly
Proprioception Post-Anterior Cruciate Ligament Reconstruction 13
motivated. If these athletes had not recovered from their ACL reconstructive surgery, it is safe
There are many ways to increase proprioception in the knees following an injury or
reconstruction of the ACL. Although there is much research on the deficits in proprioception
after injury, little is known about the timeline for proprioceptive feedback to return. Future
research on this topic should be done to investigate the potential timelines for the return of
proprioception. Additional future research includes studies of the differences between males
and females and the ACL rehabilitation process, as well as the rehabilitation process for
A significant number of studies have shown that females are much more likely to suffer
an injury to their ACL than males (Arendt, Agel, & Dick, 1999). There are numerous theories as
to why this is, but no research has been done on females and males after they have completed
the rehabilitation process following ACL reconstruction. More research should be done to
investigate if females are more likely to re-tear their ACL grafts, as well as if there is a significant
There is also conflicting research on what type of ACL graft is the best – hamstring
tendon, patellar tendon, or cadaver. Cadaver is widely accepted to be the lowest quality, but
hamstring tendon and patellar tendon each have their benefits. Research should be done to
determine if the type of graft used in an ACL reconstructive surgery has an effect on the
Conclusions
In this study, single leg balance tests did not show a significant difference in
proprioception between knees with a previously injured ACL when compared to the
and uninjured knees following ACL reconstruction, but this research was unable to definitively
replicate that. Despite this research not showing significant deficits, it is still important to
address proprioceptive changes in both knees following an injury to the ACL and subsequent
reconstruction. In order to perform at a high level, athletes must feel comfortable in the
structural stability of their knee, as well as the proprioceptive feedback they are able to receive
from their body. Implications of this research topic are applicable to athletes of all genders,
References
Arendt, EA, Agel, J, & Dick, R (1999). Anterior Cruciate Ligament Patterns Among Collegiate Men
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1322895/pdf/jathtrain00006-0014.pdf
Barrett, DS (1991). Proprioception and Function After Anterior Cruciate Reconstruction. Journal
http://www.bjj.boneandjoint.org.uk/content/jbjsbr/73-B/5/833.full.pdf
S0003999303001473-main.pdf?_tid=677f3f08-080e-11e7-9241-
00000aab0f26&acdnat=1489424541_137f9427dd50b5ea7895f4a26faacdc0.
Dhillon, MS, Bali, K, & Prabhakar, S (2011). Proprioception in anterior cruciate ligament
deficient knees and its relevance in anterior cruciate ligament reconstruction. Indian
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3134012/?report=printable.
deficiency of the anterior cruciate ligament. The Journal of Bone and Joint Surgery, 82-
B(6): 801-806.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3867093/
Proprioception Post-Anterior Cruciate Ligament Reconstruction 16
Kruse, LM, Gray, B, and Wright, RW (2012). Rehabilitation After Anterior Cruciate Ligament
Reconstruction: A Systematic Review. The Journal of Bone and Joint Surgery. American
http://journals.humankinetics.com/doi/pdf/10.1123/jsr.1.3.188.
Reider, B et al (2003). Proprioception of the Knee Before and After Anterior Cruciate Ligament
http://ac.els-cdn.com/S0749806303500081/1-s2.0-S0749806303500081-
main.pdf?_tid=df9a9822-080c-11e7-b240-
00000aacb362&acdnat=1489423884_4dbb418a81b3861a164ae5b451afb80f