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A quantitative assessment of proprioceptive function improvement after Arthroscopic ACL Reconstruction surgery.

INTRODUCTION: Injury to Anterior Cruciate Ligament (ACL) leading to functional instability of the knee is a common occurrence in young individuals. ACL injuries leading to altered neuromuscular function has been identified as a key factor for functional instability of the affected limb (1). Effects of ACL insufficiency on mechanical function of the knee has been extensively researched. There is varied literature with no clear consensus on the proprioceptive function and neuromuscular sensory function in an ACL insufficient knee. (1,2)

Proprioception has been defined by various authors as a combination of joint position, kinesthesia and also sensation of equilibrium contributing to postural control and sense of balance. (3,4,5,6)

Evaluation of position sense in the joint and kinesthesia alone do not provide adequate information on functioning of proprioceptive reflexes that seem to be responsible for the joint functional stability. (7,8)

TDPM (Threshold To Detect Passive Motion) and JPS (Joint Position Sense) test different receptors and different components of proprioception. (7,8) There are other receptors for proprioception that are not tested by these methods of evaluation and hence are not practical tools of assessment in knee injury. (7)

The symptom of instability suffered by patients after joint injury does not reflect the conscious perception of where the joint is in space, but reflex control of its activity by its musculature. (2) Therefore measurement of JPS or kinesthesia alone is not necessarily the right approach to reveal a neurological defect after joint injury, (7) hence a more functional test like postural sway (The degree of sway measured by Balance Index) which is measured by kinesthetic ability trainer is of more use functionally for the assessment of proprioceptive function. (9,10) Impairment of proprioception may lead to increased postural sway and potentially loss of balance. (11) Also, compromised knee proprioception after ACL injury have prompted researchers to study standing balance in patients with such injuries. (12,11)

Functional assessment of peripheral, visual and vestibular contributions to neuromuscular control, is best assessed by postural sway measurements for the lower extremity. (9) Stabilometric methods and instrumentation may provide a relatively accurate method for these measures. (10)

Gray et al. in 1985 defined Postural control as an ability to stand with as little sway as possible. (13) Ochsendorf et al in 2000 postulated that the ability to maintain balance demands the coordinated actuation of joint, muscle, visual and vestibular receptors (11).

MATERIALS AND METHODS: Patients presenting with symptoms of instability after a history of injury to knee were evaluated clinically with Lachman and Anterior drawer's tests. ACL tear was confirmed by MRI and all patients underwent Arthroscopic ACL Reconstruction, and all patients underwent a Neuro-muscular Training Program designed to return them to pre-injury levels.

A total number of 123 patients who had anterior cruciate ligament insufficiency of knee were included in the study.

Inclusion Criteria:

* Patients clinically and radiologically diagnosed to have isolated ACL deficiency with a normal contralateral lower limb.

* Arthroscopic ACL reconstruction with or without partial Menisectomy.

Exclusion Criteria:

* Any history of previous knee surgery.

* Significant spine disorders.

* Patients on psychotropic drugs, sedatives, vasodilators, anti-hypertensives, anticholinergics.

* Pain Score on standing (Visual Analogue scale--VAS)--greater than 4.

* Post op complications.

* Loss to follow up.

Of the 123 patients with ACL involvement, only 73(n=73) were found to be matching our criteria and hence were included in our study. Their mean ages were 27 years, with Male: Female ratio being 49:24.

Proprioceptive function testing was carried out preoperatively, postoperatively at 3 months and at 6 months Proprioceptive function testing was carried out using Kinesthetic Ability Trainer (SPORT KAT 1750).

Balance index (BI) score reflects the subject's ability to keep the platform at or near the reference position. Balance index scores range from zero to 6000, and the lower the score, better the proprioceptive function.

Study Design: The study was conducted in the Sports Medicine unit, Department of Orthopaedics, Chettinad Academy of Research and Education (CARE) between July 2014 and February 2015.

PROCEDURE (Testing Protocol): Each patient signed an informed consent and completed a questionnaire regarding past medical history and activity level. A standard set of instructions were given before each trial. The one-leg static balance test was performed with the person standing on uninjured leg first and then on the injured leg. The subject stepped onto the platform held the handrail, and placed the feet within the outline of the original foot placement. When the command "go" was given, the patient removed hands from the hand rail and stood as still as possible, and tried not to grab the handrail. The static test was performed on 1 foot with the arms crossed over the shoulders and other extremity at 20 degree flexion. Subject was told to keep the cursor at the center of the screen for 30 seconds while keeping their balance. During the measurement period the opposite leg was not allowed to touch the platform. The result was scored as the Balance index (B. I) score by the equipment. The test was repeated 3 times and mean B. I score was calculated.


* Arthroscopic ACL reconstruction was done using a Standard technique under Spinal Anesthesia with pneumatic tourniquet control. All the surgeries were done by a single surgeon who is a senior consultant at the Department.

* The Auto graft chosen was Hamstring graft using Semi T endinosis (ST) and Gracillis (G).

* In all the procedures Anatomical ACL reconstruction was done.

* The fixation was done using Endobutton in femoral side and Bio absorbable interference screw in tibial end for hamstring graft.

* Knee was immobilized with a knee brace immediately after the surgery.


* All patients followed standard rehabilitation protocols designed for ST/G graft.

* All patients were immobilized with knee immobilizer in extension for a period of 3 weeks.

* They were allowed immediate weight bearing as tolerated.

* Rehabilitation period consisted of 4 stages.

STAGE 1--(0-2 weeks):

* Immobilization in extension with knee brace

* Swelling control by Cryotherapy

STAGE 2--(3-8 weeks):

* Full weight bearing.

* Patellar mobilization.

* Hamstring stretches.

* Co-contraction exercises.

* ROM & Strengthening exercises.

* Straight Leg Raise in all planes.

* 1/2 Squats.

* Single leg standing neuromuscular training.

STAGE 3--(9-12 weeks):

* Close Kinematic Chain and Open Kinematic Chain strengthening exercises Unstable surface neuromuscular training using wobble board.

STAGE 4--(13-16 weeks):

* Advanced strengthening exercise.

* Advanced neuromuscular training in Kinesthetic Ability Trainer.

STAGE 5--(16-24):

* Plyometrics.

* Sports specific training.


* Paired t-test was used to find the significance difference between the paired samples,

* In both the above statistical tools the probability value P<. 05 is considered as significant level.

* The results were analysed using the Statistical Product and Service Solutions software (SPSS) 16.0 version.

RESULTS: The Mean BI score in the injured leg was 2203 at the time of presentation while the Mean BI score in the normal contralateral limb was 1573. The Mean BI score deficit between the injured and the normal contralateral limb was 630. There was a significant difference in proprioception between the injured limb and the normal contralateral limb (p<0.001).

The Mean BI score of the injured limb significantly improved to 1222 (p<0.001) 6 months after Arthroscopic ACL Reconstruction.

Proprioceptive function of injured limb 6 months after Arthroscopic ACL Reconstruction was comparable with that of the normal control limb (p<. 001).

Bivariate Comparison of Balance Index Scores using Paired Sample t-test (Pair 1, 2 & 3). Bivariate Comparison using Paired Sample t-test.

Table 1: Shows the Bi-Variate Comparison between the injured limb and the contralateral limb. The lower the score is, the better the proprioception.

** Highly Significant at P <0.001.

DISCUSSION: Most of the studies on Proprioceptive function assessment in ACL insufficient limbs have assessed joint position sense and kinesthesia. (7,8) They have not been able to conclusively prove the effect of Arthroscopic ACL Reconstruction on the proprioceptive function because an important functional component of proprioceptive function postural balance has not been extensively researched. (14,15)

Several authors obtained different results depending on the type of proprioceptive test used and different results have been observed in the same subject groups. (7) For example, Barrett et al showed that JPS was significantly improved by reconstruction of the cruciate ligaments. (6) However, MacDonald et al found that in patients with reconstruction of the anterior cruciate ligament (ACL) proprioception did not improve when measured by a kinaesthesia test. (16) Such contrasting results are may be due to different testing modalities and protocols used and that some authors used contralateral knee as their control while others used an external control, thus leading to conflicting observations.

TDPM and JPS test different receptors and different components of proprioception. (7) Also there are other receptors for proprioception that are not tested by these methods of evaluation and hence they may not be practical tools of assessment in knee injury. (8) A more functional test like postural sway (the degree of sway as indicated by Balance Index) measured with kinesthetic ability trainer could be used for the assessment of proprioceptive function. (10,11)

There are very few studies, (7,10) which have assessed the proprioceptive function using kinesthetic ability trainer which measures the Postural sway using Balance Index.

Our study measured the proprioceptive function using single leg stance test in a kinesthetic ability trainer. However, we found a significant deficit in proprioceptive function in the ACL deficient limb compared with the contralateral limb, this was found to be in accordance with similar studies by Arockiaraj et al and Jerosch et al who assessed postural sway. (17,18) Similarly, studies by Barrett et al and Corrigan et al who evaluated proprioception using JPS and TDPM found a significantly lower proprioceptive activity in injured knees as compared to the uninjured knees. (6)

Current research findings on the effects of ACL reconstruction on knee proprioceptive function gives no clear consensus. (1,9,12)

We found there was a significant improvement in proprioceptive function in the injured limb from time of presentation to 6 months after arthroscopic ACL reconstruction, the proprioceptive function of the ACL Reconstructed limb at the end of 6 months was found to be comparable to that of the preoperative proprioceptive function of the contralateral normal limb. Arthroscopic ACL reconstruction has significantly helped in the improvement of the injured limb.

Reconstruction of a mechanical restraint (ACL graft) seemed to have a significant positive impact on early and progressive improvement in proprioception. (5,20,21)

Arthroscopic ACL Reconstruction Seems to Improve Proprioceptive Function by:

1. By restoring a more physiological joint movement, cortical interpretation is enhanced. (5)

2. By regeneration of mechanoreceptors. (22,23)

By restoring mechanical stability with ACL reconstruction and by restoring a more physiological joint movement, cortical interpretation is enhanced and hence resulting in the improvement in proprioceptive function.


* There is a significant deficit in proprioceptive function in ACL deficient limb compared to normal contralateral control limb at the time of presentation.

* Proprioceptive function of the affected limb showed significant improvement after Arthroscopic ACL Reconstruction at the end of 6 months.

* Proprioceptive function 6 months after surgery in the ACL reconstructed limb was comparable to the pre-operative proprioception levels of the contralateral normal limb.

* Arthroscopic ACL Reconstruction significantly improves proprioceptive function.

LIMITATION: There is a lack of normative value for proprioception assessment. A wider follow up may throw light in detail analysis of proprioceptive function in patients who undergo Arthroscopic ACL Reconstruction.

DOI: 10.14260/Jemds/2015/952


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Dobson Dominic [1], P. Saravanan [2], Sai Kishore [3]


[1.] Dobson Dominic

[2.] P. Saravanan

[3.] Sai Kishore


[1.] Assistant Professor, Department of Sports Medicine & PMR, Chettinad Academy of Research & Education (CARE).

[2.] Assistant Professor, Department of Orthopaedics, Chettinad Academy of Research & Education (CARE).

[3.] Sports Physiotherapist, Department of Sports Medicine Unit, Chettinad Academy of Research & Education (CARE).




Dr. Dobson Dominic, Department of Physical Medicine & Rehabilitation, Room No. 21, E- Block, First Floor, Chettinad Hospital and Research Institute, Kelambakkam-603103, Kanchipuram District, Tamil Nadu, India.


Date of Submission: 08/04/2015.

Date of Peer Review: 09/04/2015.

Date of Acceptance: 30/04/2015.

Date of Publishing: 08/05/2015.
Table 1

PAIRS            GROUPS          MEAN S. D     T-VALUE      P-VALUE

Pair 1        Injured Limb        2203. 19     855. 15      9.702 **
           Contralateral Limb     1573. 01     638. 75
Pair 2        Injured Limb        2203. 19     855. 15     11.469 **
           Contralateral Limb     1221. 95     423. 44
Pair 3        Injured Limb        1221. 95     423. 44      5.199 **
           Contralateral Limb     1573. 01     638. 75
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Author:Dominic, Dobson; Saravanan, P.; Kishore, Sai
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:May 11, 2015
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