Systematic review
No sign of weakness: a systematic review and meta-­
► Additional supplemental
material is published online
only. To view, please visit the
journal online (https://​doi.​
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107536).
1
La Trobe Sport and Exercise
Medicine Research Centre,
School of Allied Health, Human
Services and Sport, La Trobe
University, Bundoora, Victoria,
Australia
2
Sport and Exercise Medicine
Research Centre, La Trobe
University, Melbourne, Victoria,
Australia
3
La Trobe Sport and Exercise
Medicine Research Centre, La
Trobe University, Bundoora,
Victoria, Australia
4
The Victorian Institute of Sport,
Melbourne, Victoria, Australia
5
The Australian Ballet,
Melbourne, Victoria, Australia
6
La Trobe University, Melbourne,
Victoria, Australia
Correspondence to
Professor Kay M Crossley, La
Trobe University, Melbourne,
Victoria, Australia;
​k.​crossley@​latrobe.​edu.a​ u
Accepted 28 February 2024
© Author(s) (or their
employer(s)) 2024. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Girdwood M,
Culvenor AG,
Patterson B, et al.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2023-107536
analysis of hip and calf muscle strength after anterior
cruciate ligament injury
Michael Girdwood ‍ ‍,1 Adam G Culvenor ‍ ‍,1 Brooke Patterson ‍ ‍,2
Melissa Haberfield ‍ ‍,3 Ebonie Kendra Rio,3,4,5 Michael Hedger,6 Kay M Crossley ‍ ‍6
ABSTRACT
Objective We aimed to determine hip and lower-­leg
muscle strength in people after ACL injury compared with
an uninjured control group (between people) and the
uninjured contralateral limb (between limbs).
Design Systematic review with meta-­analysis.
Data sources MEDLINE, EMBASE, CINAHL, Scopus,
Cochrane CENTRAL and SportDiscus to 28 February
2023.
Eligibility criteria Primary ACL injury with mean age
18–40 years at time of injury. Studies had to measure
hip and/or lower-­leg muscle strength quantitatively
(eg, dynamometer) and report muscle strength for the
ACL-­injured limb compared with: (i) an uninjured control
group and/or (ii) the uninjured contralateral limb. Risk of
bias was assessed according to Cochrane Collaboration
domains.
Results Twenty-­eight studies were included
(n=23 measured strength ≤12 months post-­ACL
reconstruction). Most examined hip abduction (16
studies), hip extension (12 studies) and hip external
rotation (7 studies) strength. We found no meaningful
difference in muscle strength between people or
between limbs for hip abduction, extension, internal
rotation, flexion or ankle plantarflexion, dorsiflexion
(estimates ranged from −9% to +9% of comparator).
The only non-­zero differences identified were in hip
adduction (24% stronger on ACL limb (95% CI 8% to
42%)) and hip external rotation strength (12% deficit
on ACL limb (95% CI 6% to 18%)) compared with
uninjured controls at follow-­ups >12 months, however
both results stemmed from only two studies. Certainty of
evidence was very low for all outcomes and comparisons,
and drawn primarily from the first year post-­ACL
reconstruction.
Conclusion Our results do not show widespread or
substantial muscle weakness of the hip and lower-­
leg muscles after ACL injury, contrasting deficits of
10%–20% commonly reported for knee extensors and
flexors. As it is unclear if deficits in hip and lower-­leg
muscle strength resolve with appropriate rehabilitation
or no postinjury or postoperative weakness occurs,
individualised assessment should guide training of hip
and lower-­leg strength following ACL injury.
PROSPERO registration number CRD42020216793.
INTRODUCTION
Knee muscle (quadriceps and hamstring) strength
deficits are well-­established after ACL injury and
reconstruction surgery and are a key focus of reha-
bilitation guidelines.1 2 Quadriceps and hamstring
Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536
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WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒ Thigh muscle strength deficits are common
after ACL injury, with up to 20% deficits in
quadriceps and 10% deficits in hamstring
strength reported at 12 months postsurgery.
⇒ Hip and calf muscle strength training is often
added to rehabilitation after ACL reconstruction.
WHAT THIS STUDY ADDS
⇒ Significant hip or lower-­leg muscle weakness
was not found in most planes compared with
uninjured controls or the uninjured limb in the
first 12 months after ACL reconstruction.
⇒ Hip abduction strength had the most evidence
(very low certainty), and was not different
between people or between limbs after ACL
reconstruction.
⇒ More between-­person comparisons, especially
for hip internal rotation, ankle plantarflexion
and ankle dorsiflexion are needed to inform
clinical decision-­making.
weakness can persist for up to 20 years post-­ACL
injury3 and may increase the risk of re-­injury and
post-­traumatic osteoarthritis (OA).4 5 The strength
of other lower-­limb muscles following ACL injury
is less clear, despite hip and lower-­leg (calf) muscles
playing a critical role when executing most weight-­
bearing daily activities and more complex sporting
and athletic tasks.
The hip and calf muscles are integral to knee
movements, with potential impacts on risk of knee
joint disease. Hip muscle strength is commonly
impaired in many knee conditions,6 such as
patellofemoral pain,7 patellar tendinopathy8 and
non-­traumatic knee OA,9 but consistent causal links
to the development or worsening of knee condi-
tions are not seen.7 Through its direct link to the
knee via the kinetic chain, the hip complex contrib-
utes frontal plane knee stability/control (eg, poten-
tially reducing dynamic knee valgus)10 11—which
if impaired may lead to worsening symptomatic
and structural outcomes at the knee.12 Adequate
hip muscle strength may be vital after ACL injury,
where the risk of post-­traumatic OA is significantly
higher. Lower hip external rotation strength at 1
year was associated with greater odds of worsening
knee structural outcomes 5 years after ACL recon-
struction (ACLR).13 Better hip muscle strength may
also be linked to better functional performance14—
an important benchmark for return to sport and
   1
 Systematic review
activity. Similarly, lower-­leg muscles (such as of the calf) may
impact knee function due to the gastrocnemius’ anatomical
origin being proximal to the knee. Indeed, the calf is emerging
as a key contributor to knee joint stability and compression
forces,11 15 16 with potential implications for future re-­injury and
structural outcomes following ACL injury.
Several authors have suggested hip muscle weakness might be
a problem requiring treatment after ACL injury,17–20 and reha-
bilitation trials often include hip and calf muscle strengthening
components.21–24 Yet hip and/or lower-­leg muscle strength are
not clearly summarised after ACL injury. To inform the planning
and design of future rehabilitation programmes, the aim of this
systematic review was to determine hip and lower-­leg muscle
strength in ACL-­ injured limbs compared with (i) uninjured
controls and (ii) the uninjured contralateral limb.
METHODS
This systematic review adheres to Preferred Reporting Items
for Systematic Reviews and Meta-­Analyses guidelines. It was
prospectively registered (PROSPERO: CRD42020216793)
as part of a group of systematic reviews investigating changes
in strength and functional performance after ACL injury. This
review focuses only on hip and lower-­leg strength, others will
focus on quadriceps and hamstring strength as well as functional
test performance. There were three protocol deviations. The
effect size in our analysis was changed from standardised mean
differences to the ratio of means (RoM), to enable inclusion of
studies reporting only limb symmetry indices (see ‘Data anal-
ysis’ section). This measure is also likely to be more clinically
interpretable. Second, meta-­analyses were conducted if two or
more studies were available for analysis (instead of three), given
the lack of data for some measures. Lastly, we did not present
comparisons between the uninjured leg of ACL-­injured groups
and uninjured controls, as it was beyond the scope of this paper
given the breadth of this review. All deviations were made prior
to data analysis commencing.
Eligibility criteria
We included studies of primary ACL injury (managed with
surgical reconstruction or rehabilitation) with a mean partici-
pant age of 18–40 years at the time of ACL injury. We did not
restrict inclusion on any other injury (eg, concomitant injuries),
rehabilitation (eg, type, duration) or surgical (eg, graft type)
characteristics. Studies that reported a quantitative measure of
hip or lower-­leg muscle strength measured by an isokinetic or
hand-­held dynamometer were included. Muscle strength had
to be reported for the ACL-­injured limb and (i) an uninjured
control group (between-­person comparison) and/or (ii) the unin-
jured contralateral limb (between-­ limb comparison). Studies
that reported unilateral strength without comparison, or did
not specify the injured limb (eg, reported dominant and non-­
dominant side) were excluded. We did not restrict based on
timing of strength assessment since surgery/injury. We also did
not limit based on study design, except for excluding studies of
fewer than 10 participants.
Search strategy
A search strategy was piloted based on key articles identified
in the literature and encompassed two elements: population
(ACL injury) and outcome (strength or physical performance).
We used the same search for all papers as part of this group
of reviews. Free text and Medical Subject Headings terms were
combined and tailored to each database (online supplemental
2 Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536
file 2). We searched MEDLINE, EMBASE, CINAHL, Scopus,
Br J Sports Med: first published as 10.1136/bjsports-2023-107536 on 27 March 2024. Downloaded from http://bjsm.bmj.com/ on April 12, 2024 by guest. Protected by copyright.
Cochrane CENTRAL and SportDiscus from inception to 28
February 2023, limiting to humans where possible but with no
restrictions on language. In addition, we searched OpenGrey, as
well as checking reference lists of included articles and ahead of
print sections of key physical therapy, rehabilitation and sports
medicine journals.
Study selection
Two authors (MG and either MH or BP) independently screened
titles and abstracts against eligibility criteria, before screening full
texts of relevant studies for final inclusion. Disagreements were
discussed until a consensus was reached, and a third reviewer
consulted for any disagreements as reported previously.25
Data extraction
Data were extracted using a prepiloted customised extraction
form, by one author (MG) and checked by another (MH). Infor-
mation extracted included study design, country of study, demo-
graphics for each group (eg, age, sample size, number of women,
body mass index, Tegner activity level, graft type), outcome
measure details, timepoint of data collection and outcome data
(reported as injured limb, non-­injured limb, control limb or limb
symmetry index (LSI)). For studies with multiple timepoints (eg,
cohort studies or randomised controlled trials), we extracted
data at all available timepoints. Where data were presented
only graphically, we extracted data using Plot Digitizer (V.2.6.8,
http://plotdigitizer.sourceforge.net/). Authors were contacted to
request any data unable to be extracted from the manuscript. If
no response was received after two attempts and the study had
no other data available for extraction, the study was excluded.
Non-­English studies were translated using DeepL (http://www.​
deepl.com).26
Risk of bias assessment
We assessed risk of bias according to domains outlined by
Cochrane Collaboration guidelines (online supplemental file 3)
random sequence generation, allocation concealment, blinding
of therapist and patient, blinding of assessor, outcome measure-
ment, bias in selection of participants, attrition and statistical
analysis.27 Several different study designs were included, meaning
some risk of bias domains were not assessed in many studies
(eg, bias related to randomisation or group allocation in cross-­
sectional studies). Two reviewers (MG, MH) assessed risk of bias
independently with any disagreements resolved by discussion,
and a third reviewer (AGC) consulted as required. Certainty
of evidence was defined using the Grading of Recommenda-
tions, Assessment, Development and Evaluations,28 assessed by
two reviewers (MG, AGC). We assessed the certainty for each
strength outcome and comparison (between-­person and within-­
person). As most studies were observational, baseline grading
was ‘low’, with criteria used for downgrading evidence detailed
in online supplemental table 11.3.
Data analysis
Effect sizes for meta-­analyses were calculated as ratio of means
(RoM).29 This method expresses the effect as the mean of
one group divided by the mean of the comparison. A detailed
description on the calculation of variance is published else-
where.29 30 For between-­limb comparisons (ie, within person),
these data are paired/correlated and so the RoM effect calcu-
lation is modified slightly to account for this, by providing a
correlation between limbs. As the between-­ limb correlation

was not reported by any study, we estimated this based on our
strength data as r=0.85.13 31 The RoM allows for simplified clin-
ical interpretation (eg, a RoM of 0.8=ACL limb is 0.8× strength
of the comparator, or 20% deficit), compared with traditional
metrics such as the standardised mean difference.29 The RoM is
widely used in ecological research, and allowed for incorpora-
tion of studies that present data only as LSI. For studies that only
reported LSI, we approximated these to the RoM using formulae
(online supplemental file 4). Findings that were not presented
as mean (SD) format (eg, SE, 95% CI) were transformed with
appropriate formulae.32 Data presented as median and IQRs
were transformed to mean and SD according to published
methods.33
Data were pooled based on the strength outcome (eg, hip
abduction) and the type of comparison: (i) between person
(compared with uninjured control group) or (ii) between limbs
(compared with uninjured contralateral limb). We selected the
dominant limb of the control group for comparison where
possible. To ensure data from each study were only included
once per outcome, per comparison in each meta-­analysis,34
the following decisions were used: (i) where studies reported
multiple different measures for the same outcome (eg, isoki-
netic testing at 60°/s and 120°/s), the measure that was most
similar to other studies was selected for pooling; (ii) where a
study reported outcomes across multiple timepoints, the time-
point closest to 12 months post-­injury or reconstruction was
selected. Data from <1 month postinjury/reconstruction, or
from ACL deficient groups were not included in meta-­analysis,
and were summarised narratively. Random effects meta-­
analysis with a restricted maximum likelihood estimator was
used when more than two studies were available for pooling
for each outcome and comparison. Where possible (more than
two studies), we stratified our analyses based on time since
ACLR as: (i) short-­term (≤12 months) or (ii) long-­term (>12
months). Analysis was conducted using the ‘metafor’35 and
‘meta’36 packages in RStudio.37 We calculated tau2 to assess
between-­study variance, I2 to assess total variability explained
by between-­study heterogeneity, and presented 95% predic-
tion intervals for all analyses (estimate of interval where future
observations could fall).38 We performed a leave-­ one-­out/
influence analysis to check the robustness of results for each
meta-­analysis of more than two studies39 (online supplemental
file 9), by examining the impact of removing a study on overall
estimates and heterogeneity statistics (‘influence’ command
from metafor and ‘metainf ’ from meta package). Any data
that could not be summarised quantitatively were synthesised
narratively. Scripts and all data used are publicly available:
https://github.com/mgirdwood7/hipcalf_acl_sr
Equity, diversity and inclusion statement
Our authorship team is gender balanced (four women and
three men) with early, mid and late career researchers,
although all from one country. We have made every attempt
to be inclusive of data in this review, including translating
four studies from other languages (Japanese and German),
and requesting data from authors where possible. We have
included data from 12 different countries from Europe,
North and South America, Asia, Oceania and the Middle
East, although no studies from Africa. Participants included
in this review were a mixture of men and women, although
some studies reported exclusively on men. We had hoped
Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536
Systematic review
to investigate the effects of sex and gender on findings,
Br J Sports Med: first published as 10.1136/bjsports-2023-107536 on 27 March 2024. Downloaded from http://bjsm.bmj.com/ on April 12, 2024 by guest. Protected by copyright.
however we were not powered for this.
RESULTS
The initial search yielded 11 177 unique studies (Preferred
Reporting Items for Systematic Reviews and Meta-­ Analyses
flow chart, see online supplemental figure 1.1). We included 28
studies from 12 different countries for analysis. Data from 1103
(423 women, 38%) ACL-­injured and 1145 (933 women, 81%)
uninjured controls were included, with mean age ranging from
19 to 38 years in the ACL group (table 1). All except one study40
included participants managed with surgery (all ACLR except
one study of ACL repair). Most studies measured strength in the
first 12 months postsurgery, with only three studies measuring at
>36 months postsurgery (table 1).41–43 Only six studies reported
Tegner activity levels, with mean/median scores ranging from 5
to 7.13 44 14 40 45 46 Five studies recruited specifically athletes,47–49
with two at elite levels,41 50 while four others specified recre-
ationally active populations.20 42 43 51
Isometric testing with a hand-­ held dynamometer was the
most common method of strength assessment (16 studies).
The remaining 12 studies measured slow speed concen-
tric strength using computerised isokinetic dynamometers
(≤120°/s),13 14 40 43–47 51–57 with 2 also measuring eccentric
strength.46 54 Hip external and internal rotation strength were
only measured with hand-­ held dynamometers. All studies
measuring plantarflexion and dorsiflexion strength except one58
used an isokinetic dynamometer. Method of strength assessment
for each study is listed on each forest plot and detailed in online
supplemental table 5.1.
Risk of bias
All except three studies suffered from high risk of bias of assessor
blinding (ie, the assessor was aware of the injury status of the test
limb, online supplemental file 7).55 59 60 Outcome measurement
was reliably reported with detailed methodology and low risk
of bias for all except four studies.50 52 53 58 Ten studies suffered
from unclear selection bias.40 42–44 46 47 51 56 57 61 Of the inter-
vention trials included, three out of six had high risk of bias
in randomisation methods (sequence generation and conceal-
ment), and blinding methods, respectively.40 52 53 A funnel plot
was only assessed for studies measuring hip abduction strength
comparing between limbs (n=12 studies, online supplemental
figure 6.1). On inspection, there appears some slight asymmetry
(lack of small sample studies showing hip abduction weakness
on the affected limb), although the Egger’s test was not statisti-
cally significant (intercept estimate 0.24, 95% CI −3.37 to 2.89,
p=0.87).
The certainty of evidence was rated as very low for all muscle
strength outcomes for between-­ person (online supplemental
table 11.1) and within-­person comparisons (online supplemental
table 11.2). Evidence was primarily downgraded due to risk of
bias and inconsistency, and also imprecision for some between-­
person comparisons.
META-ANALYSES
We were able to complete meta-­analyses for all main hip and
lower-­leg muscle groups (summary plots—figure 1). Detailed
plots and statistics for all meta-­analyses and sensitivity analyses
are shown in online supplemental files 8 and 9, along with raw
data from each study per outcome (online supplemental tables
12.1-­12.8).
3
4
Table 1 Study characteristics
ACL group Control group Mean (SD) Measurement
Graft/Surgical Time post-­ACLR sample size sample (n BMI, mean Tegner device, unit of Muscle strength
Study Design Country intervention (months) (n women) women) Age, mean (SD) (SD) activity level measurement outcome
Balki, Göktas59 RCT Turkey Mixed 0.1 26 (0) – 27.4 (5.9) Not reported Not reported HHD, kg Hip abduction,
hip adduction, hip
extension, hip flexion
Systematic review

Bando, et al 201761 Case-­control— Japan Not reported 8 9 (9) 22 (22) 29.7 (13.9) Not reported Not reported HHD, kgf/kg Hip external rotation,
healthy hip internal rotation
Barnett, et al Secondary analysis USA ACL repair 6 65 (37) – 19.4 (5.1) 24.7 (3.8) Not reported HHD, LSI Hip abduction
202060 of RCT cohort
Bell, et al 201662 Case-­control— USA Mixed 30.9 55 (48) 73 (60) 19.0 (1.7) Not reported Not reported HHD, kg/kg Hip abduction, hip
healthy external rotation,
hip extension, hip
internal rotation
Dalton, et al Case-­control— USA Mixed 36.4 17 (11) 17 (11) 24.5 (4.1) Not reported Not reported HHD, N/kg Hip abduction, hip
201142 healthy external rotation, hip
extension
Fukuyama, et al Case-­control— Japan Not reported 1.51 (postinjury) 20 (12) 20 (8) 24.7 (6.9) 23.3 (4.1) Not reported HHD, kgf Hip abduction,
202248 healthy hip adduction,
hip flexion, hip
extension, hip
internal rotation, hip
external rotation
Geoghegan, et al Non-­RCT UK BPTB, HS 3 22 (4) – 33.2 Not reported Not reported Isokinetic, LSI Hip extension
200752
Girdwood, et al Longitudinal cohort Australia HS-­ST 12 111 (43) – 27 25.6 Median 6 (IQR HHD, Nm/kg Hip external rotation,
202313 4–7) hip internal rotation
Hadi, et al 201953 Non-­RCT Iran Mixed 3 and 6 58 (5) – 26.7 Not reported Not reported Isokinetic, N/m/s Hip extension
Hall 2015 Cross-­sectional USA Mixed 5.7 33 (14) – 28.5 25.3 Not reported HHD, kg/kg Hip abduction
Harput, et al Cross-­sectional Turkey HS 6 72 (0) – 28 (7.6) 24.2 (4.2) 7.3 (1.4) Isokinetic, Nm/kg Hip abduction
201846
Hoch 2018 Cross-­sectional USA Not reported 84 18 (12) – 24.6 (4.6) Not reported Not reported Isokinetic, Nm/kg Plantarflexion
(knee extended),
dorsiflexion
Karanikas, et al Cross-­sectional Germany Mixed 4.5, 9 and 18 69 (not – 30.2 (7.6) Not reported 5.6 (2.8) Isokinetic, Nm Ankle plantarflexion
200444 reported) (knee extended),
dorsiflexion, hip
extension, hip flexion
Karanikas, et al Non-­RCT Germany Mixed 12 33 (not – 31.7 (10.1) Not reported 6.6 (3.0) Isokinetic, Nm Ankle plantarflexion
200540 reported) (knee extended),
dorsiflexion, hip
extension, hip flexion
Kline, et al 201814 Case-­control— USA Mixed 8.3 20 (11) 45 (22) 22.8 Not reported Median 5.5 HHD, N/kg Hip abduction, hip
healthy (range 3–9) external rotation, hip
extension
Continued

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 Table 1 Continued
ACL group Control group Mean (SD) Measurement
Graft/Surgical Time post-­ACLR sample size sample (n BMI, mean Tegner device, unit of Muscle strength
Study Design Country intervention (months) (n women) women) Age, mean (SD) (SD) activity level measurement outcome
Lima, et al 201547 Case-­control— Brazil Not reported 9.6 27 (0) 27 (0) 25.6 (5.8) 25.6 (4.4) Not reported Isokinetic, Nm/kg Hip abduction, hip
healthy adduction
Mouzopoulos, et al Case-­control— Greece Mixed 12 68 (0) 64 (0) 26.3 (4.6) Not reported Not reported Isokinetic, Nm/kg Hip flexion
201554 healthy
Myklebust, et al Prospective cohort Norway Not reported 42 80 (80) 778 (778) 23.3 (4.1) 23.4 (0.5) Not reported HHD, kg/kg Hip abduction
201741
Nicholas, et al RCT USA PT Pre-­op and 0.7 48 (19) – 32.5 (8.0) Not reported Not reported Isokinetic, LSI Ankle plantarflexion
200155 (knee extended),
ankle dorsiflexion
Noehren, et al Case-­control— USA Mixed 7.3 20 (20) 20 (20) 21.1 (5.9) Not reported 6.5 (1.6) HHD, Nm/kg Hip abduction, hip
201445 healthy external rotation
Rahova, et al Case-­control— Turkey Not reported 6 20 (0) 20 (0) 24.5 (5.3) 23.5 (1.2) Not reported HHD Hip abduction,
202250 healthy hip adduction,
hip extension, hip
flexion, hip external
rotation, hip internal

Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536

rotation
Rhatomy, et al Case series Indonesia Peroneus longus 6 31 (9) – 27.6 (8.7) Not reported Not reported HHD Ankle eversion,
201958 hallux plantarflexion
Rhim, et al 202056 Case-­control— South Korea HS Pre-­op and 12 32 (20) 32 (17) 30 (7) 22 (2) Not reported Isokinetic, Nm/kg Ankle plantarflexion
healthy (knee extended),
ankle plantarflexion
(knee flexed)
Sullivan 2022 Case-­control USA Not reported 10.4 18 (8) – 20.8 (6.3) Not reported Not reported HHD, % body mass Hip abduction
Tate, et al 201720 Case-­control— USA Mixed 32 12 (7) 12 (7) 20.8 (2.1) Not reported Not reported HHD, N/height×BM Hip abduction, hip
healthy extension
Thomas, et al Case-­control— USA BPTB Pre-­op and 7.0 15 (7) 15 (8) 20.3 (5.4) Not reported Not reported Isokinetic, Nm/kg Ankle plantarflexion
201357 healthy (knee extended),
ankle dorsiflexion,
hip abduction, hip
adduction, hip
extension, hip flexion
Tyler 2004 RCT USA BPTB 2.8 60 (27) – 36.6 (1.5) Not reported Not reported HHD, LSI Hip abduction,
hip adduction, hip
flexion
Urabe, et al 200251 Case series Japan HS-­ST Pre-­op, 3, 6, 9, 12 44 (20) – 32.7 (range 16–47) Not reported Not reported Isokinetic, Hip adduction
Nm/kg
ACLR, ACL reconstruction; BM, body mass; BMI, body mass index; BPTB, bone-­patellar tendon-­bone; HHD, hand-­held dynamometer; HS, hamstring; kgf, kg force; LSI, limb symmetry index; mixed, multiple different graft types; Nm, Newton metres;
Pre-­op, pre-­operatively; RCT, randomised controlled trial.
Systematic review

5
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 Systematic review

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Figure 1 Summary forest plot of overall meta-­analysis estimates for each outcome, for comparison with uninjured control group (left) and with
uninjured limb (right). Black diamonds are summary estimates (95% CI) from meta-­analyses with orange bands representing the prediction intervals.
Grey shaded region indicates ±10% difference in strength. ACLR, ACL reconstruction.

Hip abduction
We found no evidence for a difference in hip abduction strength
between ACL-­ injured limbs and uninjured controls (ACL
n=266, control n=926, 9 studies), or between limbs for ACL-­
injured individuals (n=473, 12 studies), for both short-­term and
long-­term follow-­ups (figure 2). Results were robust to omis-
sion of any study (online supplemental figure 9.1). One study
also measured hip abduction strength eccentrically (estimate
not included in meta-­analysis), finding no difference between
limbs.46
Hip adduction
We found 24% (95% CI 8% to 42%) stronger hip adductors on
the ACL-­injured limb compared with uninjured controls (ACL
n=62, control n=62, 3 studies, online supplemental figure 8.1),
although this result was fragile to omission of two studies (online
supplemental figure 9.2).47 57 There was no difference between
limbs in ACL groups (n=166, 5 studies, online supplemental
figure 8.1). Omission of three studies lowered I2 values, but did
not significantly alter overall estimates (online supplemental file
9.2).50 51 57
Hip external rotation
Hip external rotation strength was lower (−12% (95% CI −6%
to −18%)) in ACL-­injured people compared with uninjured
controls at long-­term follow-­ups (ACL n=72, control n=100,
2 studies), but not in the short-­term (−1% (95% CI −22% to
+25%), ACL n=49, control n=77, 3 studies, figure 3). When
pooling across all timepoints, we found no difference between
ACL groups and uninjured control groups for hip external rota-
tion strength (ACL n=121, control n=177, 5 studies, figure 3).
This result was fragile to omission of two studies,45 61 suggesting
caution in this finding (online supplemental 9.3). When
comparing between limbs in ACL-­injured groups, we found no
difference in hip external rotation strength (n=186, 3 studies),
with significant heterogeneity of effects, and overall estimate
fragile to omission of one study.62
Hip internal rotation
There was no difference in hip internal rotation strength in ACL-­
injured people compared with uninjured controls (ACL n=64,
control n=95, 2 studies, online supplemental figure 8.2). There
was no evidence for a difference in strength between limbs in
ACL-­ injured populations (n=166, 2 studies, online supple-
mental figure 8.2). Both comparisons were limited by significant
variability of findings.
Hip extension
Hip extension strength was not different between ACL-­injured
people and uninjured controls (ACL n=139, control n=182,
6 studies, figure 4), or between limbs in ACL-­injured groups
(n=304, 9 studies). Both comparisons showed considerable

Figure 2 Forest plots from hip abduction meta-­analyses for comparison with uninjured control group (left) and with uninjured limb (right). ACL
reconstruction; Con, concentric; HHD, hand-­held dynamometer; ISK, isokinetic dynamometer; RoM, ratio of means.

6 Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536

 Systematic review

Br J Sports Med: first published as 10.1136/bjsports-2023-107536 on 27 March 2024. Downloaded from http://bjsm.bmj.com/ on April 12, 2024 by guest. Protected by copyright.
Figure 3 Forest plots from hip external rotation meta-­analyses for comparison with uninjured control group (left) and with uninjured limb (right).
HHD, hand-­held dynamometer; ISK, isokinetic dynamometer; Con, concentric; ACL reconstruction; RoM, ratio of means.

variability in effects, especially when comparing with uninjured Dorsiflexion strength

controls (I2=72%, prediction interval=0.61 to 1.67). Results
were consistent for short-­term and long-­term follow-­ups, and
overall effect estimates were consistent with omission of any
study, although omission of three studies lowered I2 values
(online supplemental figure 9.3).20 44 53
Hip flexion
There was no difference in hip flexion strength in ACL groups
compared with uninjured controls (ACL n=103, control n=99,
3 studies, online supplemental figure 8.3). Comparison between
limbs in ACL-­injured people showed no difference in hip flexion
strength (n=265, 6 studies, online supplemental figure 8.3).
This finding was affected by significant variability of effects
(I2=97%, prediction interval=0.12 to 7.94). Omission of one
study54 lowered I2, but did not alter the overall estimate (online
supplemental figure 9.5).
Plantarflexion strength
Plantarflexion strength was measured by six studies. No differ-
ence was found between ACL and uninjured control groups
(ACL n=67, control n=67, 3 studies, online supplemental figure
8.4), or between limbs in ACL-­injured groups (n=175, 6 studies,
online supplemental figure 8.4). Only one study measured plan-
tarflexion strength in a knee flexed position (in addition to
knee extended position included in meta-­analysis),56 finding no
difference comparing with uninjured controls, but significantly
greater strength (10%) on the ACL limb compared with the
contralateral limb.
Four studies measured dorsiflexion strength, with no differences
shown when compared with an uninjured control group (ACL
n=35, control n=35, 2 studies, (online supplemental figure 8.5)
or to the contralateral limb (n=143, 5 studies).
Other outcomes
Two studies measured strength in the first month after ACLR and
were not included in any meta-­analyses. One study measured
hip flexor, hip extensor, hip abductor and hip adductor strength
on the fourth day after surgery, finding deficits ranging from
50% to 80% on the ACLR limb compared with the contralat-
eral limb.59 Another study investigating the impact of tourniquet
use 3 weeks postsurgery, showed ~15%–20% lower dorsi-
flexion strength, and ~10% lower plantarflexion strength (knee
flexed at 30°).55 Findings were not affected by tourniquet use.
One study measured ankle eversion and first ray plantarflexion
strength (after use of peroneus longus autograft), and found no
differences between limbs.58 Five studies measured strength pre-­
operatively,48 51 55–57 with findings summarised in online supple-
mental 10.
ACL deficient populations
One study measured non-­surgically managed ACL injuries 12
months postinjury (n=12) and found no differences between
limbs for hip extension, hip flexion, plantarflexion or dorsi-
flexion strength.40
DISCUSSION
Results from our meta-­analyses do not support the notion that
widespread hip or lower-­leg muscle weakness exists after ACL

Figure 4 Forest plots from hip extension meta-­analyses for comparison with uninjured control group (left) and with uninjured limb (right). ACL,
anterior cruciate ligament; ACLR, ACL reconstruction; CI, CI interval; HHD, hand held dynamometer; ISK, isokinetic dynamometer; RoM, ratio of means.

Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536 7

 Systematic review
injury. We found no consistent evidence for a difference between
people (ie, compared with uninjured controls), or within people
(ie, comparison with the uninjured contralateral limb), with the
largest number of studies available for hip abduction and exten-
sion strength. The only non-­zero differences identified were 12%
(95% CI 6% to 18%) weaker hip external rotators and 24%
(95% CI 8% to 42%) stronger hip adductors in the ACL-­injured
limb compared with uninjured controls, however both results
were pooled from only two studies. Certainty of evidence was
very low for all outcomes. Many between-­person estimates were
affected by low numbers of included studies, as well as heteroge-
neity of effects with wide prediction intervals, suggesting caution
in interpreting these findings. Individualised assessment should
guide prescription of hip and lower-­leg muscle strengthening.
Our review provides the first comprehensive summary of hip
and lower-­leg muscle strength after ACL injury. Contrary to our
expectations, there was no consistent evidence for widespread
lower-­ limb muscle weakness (ie, across different movement
directions), nor weakness with large effect sizes. SE of measure-
ment for hip and lower-­ leg strength assessment is generally
between 5% and 10%.63–65 Acknowledging the limitations of
sample sizes and variability of study effects, almost all of our
point estimates and summary findings (except for hip adduction
strength) showed muscle strength outcomes within 5%–10% of
the comparator (most data from 6 to 12 months post-­ACLR),
suggesting even with these limitations, major weakness such
as is commonly reported for the quadriceps and hamstrings is
unlikely to be present in the hip and lower-­leg muscles after ACL
injury.
Quadriceps and hamstring weakness is near universal after
ACL injury and a major clinical impairment that continues to
be a challenge, despite extensive rehabilitation efforts.23 Based
on our findings, persistent weakness may be contained to the
thigh muscles. Pain, effusion and immobilisation caused by ACL
injury and reconstruction undoubtably affect the knee the most,
however it is surprising that other lower-­limb muscles such as
the hip and calf appear unaffected, given their critical contribu-
tions to knee movement and control. Unlike the thigh, the hip
and lower-­leg muscles could be less affected by central nervous
system changes postinjury/surgery,66 that contribute to persistent
thigh muscle weakness. The hip and calf are also unlikely to be
affected by significant arthrogenic muscle inhibition or changes
to activation commonly seen in the quadriceps and hamstrings
as a result of pain and effusion at the knee joint.67 68 Certainty
of evidence was very low for all outcomes, and most studies
reported strength between 6 and 12 months post-­ACLR). As
further evidence emerges, it is possible our results could change.
Hip abduction strength had the most evidence, with narrow
prediction intervals, where new papers are unlikely to alter our
estimates, although certainty of evidence was still very low.
Current rehabilitation approaches for the hip and lower-­leg
muscles may adequately restore comparable muscle strength to
the levels of uninjured controls. Training non-­thigh muscles is
frequently recommended for knee injury rehabilitation (including
ACL injury).24 69 No ACL clinical guidelines specifically recom-
mend hip or calf muscle strengthening,70 nor do major inter-
vention studies measure the impact of training these muscles.
Unfortunately, rehabilitation was often insufficiently described
in the included studies, leaving us to speculate. Rehabilitation
completion and adherence was likely variable for participants in
these studies, as previous studies have reported <50% of people
engaged with a therapist for rehabilitation beyond 3 months
post-­ACLR.71 On the other hand, some participants may have
had structured training as part of study protocols in randomised
8 Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536
controlled trials. Although it is possible that non-­thigh muscles
Br J Sports Med: first published as 10.1136/bjsports-2023-107536 on 27 March 2024. Downloaded from http://bjsm.bmj.com/ on April 12, 2024 by guest. Protected by copyright.
were not overly impaired pre-­injury or postsurgery, this seems
less likely, as hip muscle weakness is evident in some people pre-­
injury,72 and two studies included in this review showed large
deficits in hip and lower-­leg strength in the first 2–3 weeks postre-
construction.55 59 Further longitudinal studies measuring muscle
strength across multiple timepoints may help to understand the
trajectory and cause of any hip muscle strength changes.
Thigh muscle weakness after injury may increase the demand
on hip and lower-­leg muscles, and these non-­knee muscles may
need to be stronger than in uninjured people. Indeed, our results
showed stronger adductors in the ACL-­injured limb compared
with uninjured controls. Other studies have found greater
hip extension strength in those with weaker quadriceps after
ACLR,62 and change to a more ‘hip-­dominant’ strategy shown
across movements such as hopping.73 Before we can recom-
mend training a more hip dominant strategy to compensate for
quadriceps weakness, we need to determine whether a clinically
meaningful link exists between greater hip strength and better
structural and self-­reported outcomes, and whether this can be
targeted with tailored strength training.
For clinicians, restoring hip muscle strength may still be a
priority—individualised assessment of the impairments and
goals of each person should be considered.22 24 However, our
results might indicate that routine isolated hip muscle strength
training may not be necessary in all people after ACL injury,
acknowledging that wide prediction intervals for some results
(eg, hip extension) could suggest significant variability from our
estimates in some people. Many of our results are from data
between 6 and 12 months post-­ACLR, although deficits might
still be present earlier post-­operatively. Maintenance of strength,
particularly in the early postoperative phase, may be another
justification for adding hip and calf training to rehabilitation.
Incorporating multijoint movements, functional tasks and closed
kinetic chain exercises will also target the broader kinetic chain,
including the hip and lower-­leg muscles. Targeting the hip and
calf muscles may also benefit athletic performance. Guidelines
and consensus exercises recommend a key focus on regaining
quadriceps strength after injury,70 74 and this should remain a
top priority.2 For participants with hip and lower-­leg muscle
impairments identified during rehabilitation, targeted strength
training may be appropriate. Monitoring hip muscle strength is
feasible and reliable in the clinic with a hand-­held dynamometer,
and can be used to guide training goals.64 75 Hip and lower-­leg
muscle strength within 5%–10% of either normative data, or the
contralateral leg may be an indicative standard for people to aim
for after ACL injury.
This review has several limitations. Many comparisons were
affected by small number of studies and included participants.
Where possible (more than two studies), we conducted a leave-­
one-­out sensitivity analysis to assess the robustness of findings,39
and overall effect estimates for most outcomes were unaffected
by removal of a study. Almost all included studies failed to
blind the outcome assessor (ie, strength tester), which is rele-
vant given assessor encouragement can impact the voluntary
effort needed to achieve an accurate measure of peak strength.
It may also be important for hand-­held dynamometry where
the assessor must match or break the force. Many case-­control
studies were also affected by unclear selection bias, a common
problem for this research design,76 likely adding to uncertainty
of prediction intervals. Comparison with an uninjured control
group is important for outcomes such as muscle strength, as
comparing with the uninjured contralateral leg may be affected
by confounding factors including weakness pre-­injury, reduced

activity post-­injury and central nervous system changes.77 78 We
identified two additional studies unable to be included,79 80 with
hip strength outcomes reported without specifying the injured
limb, or reported only as a strength ratio (eg, abduction:ad-
duction ratio). We are also aware of five studies measuring hip
muscle strength in adolescent/paediatric populations which did
not fit our criteria.81–85
Another limitation was the pooling of different contraction
types and strength testing methods (eg, concentric and isometric
tests), which may have diluted any potential deficits. Isometric
contractions may be more sensitive to showing asymmetries, as
muscles can exert higher force during isometric contractions,
compared with concentrically.86 87 Similarly, the hip muscles are
often tested in different positions (eg, in hip neutral vs 90° hip
flexion for hip rotation strength), influencing length-­ tension
relationships which could explain some of the variability seen
in our estimates.
Results from our review are most generalisable to young (age
<30 years) people after ACLR from western countries. Results
may be different in ACL deficient populations as well as in
older or less athletic groups. We have made every attempt to be
inclusive of data, including translating four studies from other
languages and requesting data from authors where possible.
Measuring differences between genders for strength was beyond
the scope of this review, and three studies included cohorts of
predominantly men. Differing timepoints and graft types may
also have added to heterogeneity of effect estimates. Only four
studies measured strength beyond 36 months after surgery, with
the majority of our data from the short-­term postsurgery (<12
months post). Lastly, most strength tests used were short dura-
tion and isometric, which may not capture all possible deficits
(eg, eccentric contraction, muscle endurance).
CONCLUSION
Major and widespread hip and lower-­leg muscle weakness was
not a feature after ACL injury. This finding held true, irrespective
of comparison group (uninjured controls or uninjured contra-
lateral limb), but was informed by very low certainty evidence
mainly from 6 to 12 months post-­ ACLR. The most robust
evidence was for hip abduction strength, where new research is
unlikely to change our estimates, showing no difference in the
ACLR limb compared with a control group, or when compared
with the contralateral limb. Hip internal rotation, ankle plantar-
flexion and dorsiflexion strength suffered from a lack of data in
case-­control comparisons, with limited clinically useful findings.
For clinicians, training and rehabilitation decisions should be
based on individualised assessment of hip and lower-­leg strength,
as currently it is unclear whether no postinjury weakness arises,
or deficits resolve with appropriate rehabilitation.
Twitter Michael Girdwood @m_girdwood, Adam G Culvenor @agculvenor, Brooke
Patterson @Knee_Howells, Melissa Haberfield @melhabphysio, Ebonie Kendra Rio
@tendonpain and Kay M Crossley @kaymcrossley
Contributors MG, AGC, KMC designed the research question. MG performed the
searches. MG, BP, MH screened titles and full texts. MG and MH performed risk of
bias assessment. MG performed all data reduction and analysis. MG interpreted the
findings and drafted the manuscript. All authors read and gave feedback on the final
manuscript. KC is the guarantor of this work.
Funding MG is supported by a National Health and Medical Research Council
Postgraduate award (GNT1190882). AGC is the recipient of a National Health and
Medical Research Council Investigator Grant (GNT2008523).
Competing interests KMC holds a research grant from Levin Health. BP, AGC and
EKR are Associate Editors at the British Journal of Sports Medicine. KMC is a Senior
Advisor to the British Journal of Sports Medicine.
Patient consent for publication Not applicable.
Girdwood M, et al. Br J Sports Med 2024;0:1–11. doi:10.1136/bjsports-2023-107536
Systematic review
Provenance and peer review Not commissioned; externally peer reviewed.
Br J Sports Med: first published as 10.1136/bjsports-2023-107536 on 27 March 2024. Downloaded from http://bjsm.bmj.com/ on April 12, 2024 by guest. Protected by copyright.
Data availability statement Data are available in a public, open access
repository.
Supplemental material This content has been supplied by the author(s). It
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
been peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
ORCID iDs
Michael Girdwood http://orcid.org/0000-0001-6477-7263
Adam G Culvenor http://orcid.org/0000-0001-9491-0264
Brooke Patterson http://orcid.org/0000-0002-6570-5429
Melissa Haberfield http://orcid.org/0000-0002-6366-0896
Kay M Crossley http://orcid.org/0000-0001-5892-129X
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