Original Article 51

Cross-Exercise on Quadriceps Deficit after ACL

Reconstruction
Maria Papandreou, Ph.D. 1 Evdokia Billis, Ph.D. 2 George Papathanasiou, Ph.D. 1
Panagiotis Spyropoulos, Ph.D. 1 Nikos Papaioannou, Ph.D. 3

1 Department of Physiotherapy, Technological Education Institute of Address for correspondence and reprint requests Maria Papandreou,
Athens, Faculty of Health Sciences and Caring Professions, Athens, Ph.D., Lecturer in Physiotherapy, 9 Poseidonos Avenue, Marathonas
Greece 19007, Greece (e-mail: mpapand@[Link]).
2 Department of Physiotherapy, Technological Education Institute of
Patras, Faculty of Health Sciences and Caring Professions, Aigio,
Patras, Greece

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3 Laboratory for the Research of Musculoskeletal System, University of
Athens, Athens, Greece

J Knee Surg 2013;26:51–58.

Abstract A few studies concerning the improvement of quadriceps muscle strength deficit (QD)
at an early stage following anterior cruciate ligament (ACL) reconstruction have been
conducted whereas, ACL rehabilitation protocols based on contralateral quadriceps
strength (QS) do not exist. Given these, the goals of our study were (1) to evaluate the
effects of cross-eccentric exercise (CEE) on QD on ACL reconstructed knees, and (2) to
explore any changes in QD following CEE provided at the frequencies of 3 or 5 times per
week. For this study, 42 ACL-reconstructed patients were randomly assigned into
3 groups, two experimental and one control and followed an 8-week rehabilitation
program. Additionally, the experimental groups received CEE for 3 and 5 days per week
for 8 weeks in their uninjured knees. QS was evaluated with an isokinetic/isometric test,
at 60 degrees of knee flexion of both limbs before and after completion of CEE. Two-
Keywords factor ANOVA showed a significant improvement of QD between groups (F ¼ 5.16,
► cross-education p ¼ 0.01) after CEE completion on ACL reconstructed knees. Statistically significant
► bilateral training results arose from the 3 days per week (D ¼ 18.60, p ¼ 0.01) and 5 days per week
► quadriceps deficit (D ¼ 15.12, p ¼ 0.04) experimental groups, whereas the control group did not yield
► eccentric exercise any statistically significant differences. CEE used as an adjunct to the ACL traditional
► anterior cruciate rehabilitation program at the weekly frequencies of 3 and 5 times at the early stage of
ligament reconstruction significantly improved QD.

Following anterior cruciate ligament (ACL) surgery significant Quadriceps muscle activity causes anterior tibia transla-
quadriceps muscle strength deficit (QD) usually for up to 20% tion between 20 and 60 degrees of knee flexion8,9 and this is
compared with the uninjured knee in the first 4 weeks has closely related to the increased ACL strain levels at these
been reported.1–4 And, preoperative quadriceps strength (QS) angles.10–12 Thus, the fact that QD is greater at the knee range
has been found as one of the important predictors for knee of 60 degrees10–13 following ACL reconstruction, might be
function for as long as 2 years after ACL reconstruction.5–7 attributed to the interrelation between quadriceps activity
However, so far, there is no agreement as to what is the ideal and ACL strain levels following the operation graft technique.
treatment for postoperative quadriceps weakness for indi- These findings seem to justify the specific focus of the exercise
viduals after ACL reconstruction. rehabilitation program at 60 degrees of motion, in the early

received Copyright © 2013 by Thieme Medical DOI [Link]

February 23, 2011 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0032-1313744.
accepted after revision New York, NY 10001, USA. ISSN 1538-8506.
January 22, 2012 Tel: +1(212) 584-4662.
published online
May 15, 2012
52 Cross-Exercise after ACL Reconstruction Papandreou et al.

stage after ACL reconstruction.10–13 As a consequence, for Diego, CA), (4) be between levels C and D in the objective part
ACL-reconstructed patients an optimizing postoperative re- of 2000 International Knee Documentation Committee17
habilitation program for alleviating QD, through the safest knee examination form (surgical part), indicating abnormal
and most expeditious means available is recommendable. or severely abnormal knee function, and (5) score between 0
Such a safe, practical, economic, and potentially beneficial and 5 in activity levels in recreational or sports activities as
form of exercise is contralateral or cross-exercise (CE). assessed by Tegner activity score questionnaire (►Table 1).18
CE focus on exercising the contralateral limb to increase Patients were excluded if they had clinical varus/valgus
the strength in the homologous muscle on the untrained laxity or symptomatic meniscal injuries, painful knee active
limb, without directly involving the latter in the motor range of motion, joint swelling, leg length discrepancy,
activity.14 CE is a safe form of exercise, because exercise of cartilage lesions affecting the subchondral bone, fractures,
one limb can produce a beneficial effect in the contralateral and a history of lower extremity pain in the last 6 months that
limb for patients who have conditions that prevent them from did not agree with the ACL-rehabilitation requirements.
exercising a limb.14 An arthroscopically assisted autograft technique was used
However, the clinical significance of this intervention has by the same surgeon, using the semitendinosus and gracilis

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not been critically evaluated for special population groups tendons in quadrapted fashion as a graft source.19 Before
such as, postoperative patients versus unexercised control inclusion, all patients signed a written informed consent
groups. form.
Thus, it is not unreasonable to assume that cross-eccentric
exercise (CEE) applied at a higher than 3 days per week Outcome Measure
frequency (such as 5 days) as an adjunct to the traditional All patients were evaluated in two phases; 1 week preopera-
ACL rehabilitation program may improve QD at 60 degrees on tively and 9 weeks postoperatively.
ACL-reconstructed knee in the early ACL-postoperative stage. QS was tested with isokinetic dynamometer (Kin Com AT+,
The goals of our study were to explore (1) the effects of an Chattanooga Group Inc., Chattanooga, TN) by performing
8-week CEE program on QD at 60 degrees of flexion on ACL- three maximum isometric contractions of 5 seconds each
reconstructed knees and (2) any changes in QD when apply- at 60 degrees of knee flexion at each knee. Patients performed
ing CEE for 3 or 5 times per week in the early stage of ACL four repetitions as a practice trial before testing. The unin-
reconstruction. jured knee was tested first and was followed by the ACL-
injured one. Visual and verbal encouragement was provided.
Isokinetic peak torque values were measured in Newton
Methods
meters (Nm) for both limbs at 60-degree knee flexion angle.
This study received ethical approval from the Committee of Leg dominance was assessed on the basis of a question-
Laboratory for Research of Musculoskeletal system at the naire consisting of six questions specifically selected from the
University of Athens. literature as highly reliable.20,21 Of the 42 participants,
12 were left-leg dominant, 8 had equally dominant sides,
Sample and 22 were right-leg dominant (►Table 1).
Participants consisted of male patient soldiers in the Greek
army referred from the outpatient Orthopaedic and Physical ACL Rehabilitation Program
Therapy department of General Army Hospital 401 (GAH 401) All subjects commenced the ACL rehabilitation program
in Athens, with unilateral ACL ruptures confirmed by both 1 week following reconstruction at a 5-day weekly frequency
magnetic resonance and clinical examination performed by (Monday to Friday) for 8 weeks.
the same orthopedic surgeon. All subjects received the same ACL rehabilitation program,
Out of the 58 patients initially assessed, 42 met the which was divided into two subsequent phases; the progres-
inclusion criteria for eligibility in the study, and were ran- sive 8-week program corresponded to phase 2 according to
domly assigned (by flip coin) into one of three groups, two Wilk et al22 and Majima et al23 rehabilitation principles
experimental ones (Groups A and B) and one control (►Table 2).
(Group C). The 8-week time interval for rehabilitation was considered
Our sampling selection is included in stratified random appropriate and adequate for resolving knee impairments
sampling. A power analysis performed before the study and (swelling pain), range of motion deficits, restoring muscle
14 subjects comprised each one of the three groups. Patients' strength, and neuromuscular responses. Additionally, the
characteristics and admission profiles are illustrated 8-week duration is related to the graft vascularization
in ►Table 1. phase24–26 as well as specific biochemical, mitochondrial,
To be considered eligible for inclusion patients had to: and neurological muscular adaptations to take place.1,3
(1) be between 20 and 25 years of age, (2) have a complete Consequently, we hypothesized that this duration could be
rupture of ACL within the past 40 days to 6 months (subacute critical in establishing a strength stimulus on QD after ACL
phase of ACL injury)15,16 with no other recent or previous reconstruction. The program was delivered by two highly
injuries that demanded surgical reconstruction, (3) have at experienced musculoskeletal physical therapists of the Phys-
least 3 mm of bilateral difference in anterior knee joint laxity, iotherapy Department of 401 GAH (mean musculoskeletal
as measured by KT1000 knee arthrometer (MEDmetric, San experience: 5 years).

The Journal of Knee Surgery Vol. 26 No. 1/2013

 Cross-Exercise after ACL Reconstruction Papandreou et al. 53

Table 1 Subjects' Characteristics and Admission Criteria (Mean  SD)

Subjects Characteristics Group A (3 d/wk) (n ¼ 14) Group B (5 d/wk) (n ¼ 14) Group C (Control) (n ¼ 14)
Age (y) 23.64  2.56 25.07  2.40 23.14  2.71
Weight (kg) 81.28  8.40 82.50  9.83 75.00  8
Height (cm) 179.07  5.18 182.21  4.70 175.85  5.78
2
BMI (kg/m ) 24.80  2.20 25.24  2.90 25.80  4.73
Time of ACL injury (months) 4.42  1.79 4.42  1.75 3.67  1.78
a
SD (KT-1000) (mm) 5.57  2.40 6.35  1.21 5.92  2.12
Tegner activity score (0–10) 3.07  1.32 3.28  1.32 2.92  1.43
Right-leg dominant(n ¼ 22)b n ¼ 7 (2.94%) n ¼ 7 (2.94%) n ¼ 8 (3.36%)
Left-leg dominant(n ¼ 8) b
n ¼ 3 (1.26%) n ¼ 2 (0.84%) n ¼ 3 (1.26%)

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Equally dominant legs (n ¼ 12) b
n ¼ 4 (1.68%) n ¼ 5 (2.1%) n ¼ 3 (1.26%)
a
Side-to-side difference: (SD) of tibia anterior translation on the injured side in millimeter.
b
Leg dominance and percentage of dominant and non-dominant legs in each of the three groups.
ACL, anterior cruciate ligament; BMI, body mass index; SD, standard deviation.

Prior to the commencement of the study the principal effusion (as measured by joint circumference), walking inde-
investigator adequately trained the two involved therapists to pendently, 0- to 100–120-degree knee motion, straight leg
standardize their rehabilitation procedure. raising in all planes, low resistance (10 reps), and multiple
All patients were instructed to wear their functional brace reps (20) with no extension lag and mini-squats 0 to
and use crutches for 6 weeks during their daily activities To 100 degrees.
ensure that all patients received similar amounts of exercise, a
home exercise program was not given. CEE
After completion of the 8 weeks of ACL rehabilitation The CEE program was designed based on previous stud-
program, patients had to meet the following criteria: no ies,27–29 as specific evidence-based guidelines for CEE on
pain (as indicated with a 10-cm visual analog scale), no quadriceps in the early stage after ACL-reconstructed stage

Table 2 ACL Postoperative Rehabilitation Program22,23

Postoperative Phase Rehabilitation Regimen

Phase 1; Duration 2–4 wk • Immediate straight leg raising
• Early range of motion exercise with an emphasis on gaining
full knee extension (0 degrees)
• Weight-bearing full as tolerated
• First week 70-degree flexion
• Static squat (90-degree flexion)
Phase 2; Duration 2–3 mo • Endurance training (biking)
• Progressive resistance training (leg press, calf press, step up)
• Dynamic squat (0–110 degrees)
• Balance exercises
• Eccentric muscle contractions
• Progressive resistance exercise full range of motion, hop on one leg without pain
• Isokinetic exercise and assessment
Phase 3; Duration 3–6 mo • Continued progressive resistance and endurance training
• Jogging/running, swimming
• Eccentric training (active lengthening force production, such as jumping exercises)
• Strengthening and functional exercise training to prepare the individual for
full return activity
• Criteria for returning to full activity:
• 80% strength and 85% functional ability, proprioception >90%
• Extension/flexion strength difference >70% compared with the nonsurgical lower
extremity and Lysholm knee score >90
Functional brace 6 wk

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54 Cross-Exercise after ACL Reconstruction Papandreou et al.

Table 3 Quadriceps Strength (QS) Changes (Pre- and Postoperatively) Across the Groups

Groups " QS% Uninjured Kneea ↓ QS% Injured Kneeb

Mean  SD
Group A (3 d/wk) " 22.70  20.60 ↓ 16.25  24.70
Group B (5 d/wk) " 18.00  17.60 ↓ 6.30  26.01
Group C (control) " 14.08  16.20 ↓ 37.83  16.90
a
" QS%, an increase of percentage in quadriceps strength.
b
↓ QS%, a decrease of percentage in quadriceps strength.
QS, quadriceps strength; QS%, percentage quadriceps strength; SD, standard deviation.

do not exist. Cross-training was an eccentric exercise pro- Two-factor ANOVA (group  time) was applied to test for
gram applied on quadriceps' uninjured knee which started group differences in QD percentage ([preoperative QS: in-

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concurrently with the ACL physiotherapy program. jured  uninjured] – [postoperative QS: injured  unin-
The basic exercise was one repetition maximum (1 RM) of jured] /100); where the group factor had three levels
eccentric contraction (knee extension to flexion) on the iso- (Groups A, B, and C), and the time factor had two levels
tonic (concentric/eccentric) leg extension machine, whereas (pre- and postoperatively).
resistance was placed just above the medial malleolus.27,30 Body mass was used as a covariate in the analysis, as there
The intensity of the eccentric exercise program was sub- were differences in the body weight between groups. Post hoc
maximal 80% of 1 RM, because it has been reported to have analysis based on Tukey HSD criterion was applied to determine
greater strength adaptations than maximal ones.27,31–33 So, the location of group differences of QD on ACL-reconstructed
the resistance used ranged from 60.85  13.93 kg for the first knees after CEE application. Results were considered statisti-
and 61.50  11.40 kg for the second experimental group. cally significant if p values were less than 0.05. All data were
The CEE consisted of two warm up sets with no loads, analyzed using SPSS software (IBM Software, Armonk, NY).
following by five sets of six repetitions at 80% of 1 RM with
two minutes of rest between sets.27,29,30
Results
The first experimental group (Group A) undertook the CEE
at a frequency of 3 days per week (E1–3d/w), the second QS changes from preoperatively up to 8 weeks postoperative-
experimental group (Group B) at 5 days per week (E2–5d/w), ly across the groups are shown in ►Table 3. An increase of QS
whereas the control group (Group C) undertook only the ACL was evident for the uninjured knees across the groups
rehabilitation program. postoperatively, in contrast to the injured knees, which
The CEE program and the intensity were standardized demonstrated a decrease in QS for all groups
throughout the 8-week period to monitor all patients, and (postoperatively).
facilitate clinical applicability of the procedure. Quadriceps absolute strength and percentage changes in
QD between the injured and uninjured knees for the groups
are shown in ►Tables 4 and 5.
Data Analysis
Changes in postoperative QD between knees were for the
Mean values and standard deviations were calculated for the first experimental group (Group A) from 12.17 to 27.95%, for
isometric QS profile for each knee across the three groups. the second (Group B) from 17.22 to 29.82%, and for the control
One-way ANOVA was used for calculating any QS changes group from 24.32 to 53.00% (►Table 5).
percentage from pre- to posttest for both, the injured and One-way ANOVA showed that there was no significant
uninjured knees (pre- minus posttest/100) separately across interaction effect on QS scores in uninjured knees between
the three groups. Post hoc analysis based on Scheffe criterion the groups (F ¼ 0.781, p > 0.05) when eccentric exercise
was applied to determine the location of group differences. program was conducted.

Table 4 Quadriceps Absolute Strength and Changes in QD% between Knees Preoperatively

Groups QS Uninjured QS Injured QD%

Uninjured-Injured
Mean  SD
Group A (3 d/wk) 437.40  178.54 420.64  84.74 12.17  9.30a
Group B (5 d/wk) 371.35  93.50 315.31  91.00 17.22  15.45a
Group C (control) 418.90  112.10 354.05  127.50 24.32  17.95
a
Significantly less than the control group (p < 0.05).
QD%, percentage quadriceps muscle strength deficit; QS, quadriceps strength; SD, standard deviation.

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 Cross-Exercise after ACL Reconstruction Papandreou et al. 55

Table 5 Quadriceps Absolute Strength and Changes in QD% between Knees, at 8 Weeks Postoperatively

Groups QS Uninjured QS Injured QD% Uninjured-Injured

Mean  SD
Group A (3 d/wk) 458.75  87.33 344.80  135.23 27.95  24.20a
Group B (5 d/wk) 394.00  91.20 295.50  84.80 29.82  21.05a
Group C (control) 487.95  108.33 225.30  122.30 53.00  24.20
a
Significantly less than the control group (p < 0.05).
QD%, percentage quadriceps muscle strength deficit; QS, quadriceps strength; SD, standard deviation.

However, for the injured knees, a significant interaction The results of this study revealed changes in both knees: a
effect on QS scores was evident among the groups (F ¼ 6.95, strength increase of 14 to 22% for the uninjured knees across

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p < 0.05) following CEE. In particular, post hoc analysis the groups, and a decrease of 6 to 16% for the two experi-
determined that the significant results arose from the first mental groups and 37% for the control one for the injured
experimental group compared with the control (D ¼ 21.60, ones; 8 weeks following the ACL reconstruction (►Table 3).
p ¼ 0.04), and from the second one compared with the Evaluation of QD showed changes in percent from 12 to
control one (D ¼ 31.60, p < 0.001) (►Fig. 1). 24% to 27 to 53% from preoperatively to 8 weeks postopera-
Two-factor ANOVA showed that there was a significant tively for the three groups (►Table 5). Our QD values, irre-
interaction effect on QD percentage between groups and time spective of the supplementary CEE program performed,
(F ¼ 5.16, p < 0.001) after the 8-week CEE program, on the emphasizes that patients with ACL reconstruction in the early
reconstructed knees. Post hoc analysis by Tukey HSD deter- stage of rehabilitation showed particular interesting changes
mined that the significant results arose from both experi- in QS from pre- to posttest. These results are confirmed by
mental groups compared with the control one (Group A: previous findings, where postoperative QDs have been found
D ¼ 18.60, p ¼ 0.01; Group B: D ¼ 15.12, p ¼ 0.04), between 10 and 20%,1,3,6,7,34,35 despite the plethora of the
(►Fig. 2). progressive and accelerated exercise programs, for ACL-
The covariate body mass did not have a confounding effect reconstructed patients, long-term impairments often
on the groups' results in the research procedure (F ¼ 0.00, persists.3,7,34,35
p ¼ 0.97, p > 0.05). The corresponding QS values for the uninjured knee en-
tailed increases, it would appear logical that 8 weeks of
eccentric exercise program on a healthy trained limb have
Discussion
potential improvement. On the other hand, the status of the
The purposes of this study were to investigate whether uninjured side may lead to misinterpretation of results due to
8 weeks of a CEE program could offer more improvement possible bilateral neuromuscular changes after injury.
or minimize quadriceps muscle strength deficit at 60 degrees
of knee flexion, by either being applied at 3 or 5 times per
week, in the early postoperative stage of ACL reconstruction.

60

Injured knees
Quadriceps strength deficit scores %

450 50

400
Quadriceps strength scores

350 40
Group A
300
Group A 30 Group B
250
Group B
200 C
C 20
150
100 10
50
0 0
Preoperatively Postoperatively Preoperatively Postoperatively
Quadriceps strength pre to postoperatively QD% between groups and time
across the groups on the reconstructed knees

Figure 1 A significant interaction effect of contralateral-eccentric Figure 2 A significant interaction effect of CEE on quadriceps changes
exercise (CEE) on quadriceps strength (QS) arose from Group A in quadriceps deficit (QD) percentage arose from Group A (3 d/wk) and
(3 d/wk) and Group B (5 d/wk) compared with the control one, at Group B (5 d/wk) compared with the control one, at 8 weeks
8 weeks postoperatively. postoperatively.

The Journal of Knee Surgery Vol. 26 No. 1/2013

56 Cross-Exercise after ACL Reconstruction Papandreou et al.

The results confirmed our first hypothesis that adding CEE compared with a rehabilitation one performed alone. Where-
to the traditional ACL rehabilitation program would lead to as, no reports have implicated that a particular frequency of
significant improvements of QD at 60 degrees of flexion in exercise has the greatest amount of CEE benefits on QD.
ACL-reconstructed patients. This was evident for subjects Several different training protocols designed to explore CE
classified in experimental groups, received CEE 3 or 5 days gains and adaptations comparing different kinds of exercise
per week. Both experimental groups showed a significantly programs (isometric, eccentric, concentric, etc.) have been
less quadriceps muscle strength deficit compared with the limited to the training frequency of 3 days per
control one, 8 weeks after the ACL postoperative rehabilita- week.14,27,33,36–39 All the above studies used a 4- to
tion phase (►Table 5). 12-week training program and only a limited number of
This improvement on QD could be attributed to cross studies have explored CE in patients following ACL recon-
eccentric exercise. As far as the type of CE is concerned, struction.40,41 Nevertheless, further research should explore
eccentric exercise has been found to be superior to isometric different exercise frequencies in CE for this patient
or concentric exercise and seems to have the greatest effect on population.
QS accounting for the greater increases in eccentric and From our findings it can be stated that it is possible to

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isometric forces.31–33,36–39 achieve significant and clinically important improvements in
As a consequence, our results emphasize that patients with QD adding the CE as an adjunct rehabilitation program to the
ACL reconstruction, in the early stage of rehabilitation, have traditional ACL one, at the early phase of reconstruction.
potential for clinically relevant QS improvement at 60-degree A crucial issue when introducing progressive exercise
knee flexion when CEE is conducted as a supplement to therapy programs is the tolerance for the training load
the ACL traditional rehabilitation program. through a neural mechanism which produces the earliest
ACL postoperative quadriceps muscle strength deficit have activation of central nervous system. As far as the mechanism
not previously been assessed using CE as supplementary of action of CE is concerned, it is believed to be mediated by
exercise program to the traditional rehabilitation one. Limit- neural mechanisms including diffusion of impulses between
ed studies have been reported on the effect of CE on patient hemispheres, coactivation via bilateral corticospinal path-
population. It has been reported that CEE improves quadri- ways, postural stabilization, and the cerebral cortex
ceps muscle strength at 45- and 90-degree knee angles and theory.14 This latter theory has been referred to as the
quadriceps accelerated reaction time at 90 degrees of knee most dominant mechanism acting via the voluntary contrac-
flexion on the ACL-reconstructed knee in the early rehabili- tion of a specific muscle—on the trained side—and then a
tation stage; 8 weeks following the reconstruction.40,41 Arai facilitation effect is produced at the same motor point in the
et al42 investigated, in six orthopedic patients, the effect of CE opposite side via the cerebral cortex.28,29,45
on QS by applying a proprioceptive neuromuscular Future randomized controlled trials including treatment
facilitation (PNF) exercise, at various knee angles. The PNF- groups with larger sample sizes testing different frequencies
CE was significantly effective on QS at 60 degrees of knee of CE programs are needed to verify the potential effective-
flexion. ness of this proposed program.
The limited amount of information for QD following CE in
the early stage of ACL reconstruction should be addressed in Limitations
future studies. Although, an assessment of which was the dominant limb was
The second purpose of this study explored the most provided, due to the study design and to our small sample we
effective CEE frequency between the frequencies of 3 and did not determine the effectiveness of CEE after the ACL
5 days per week (experimental groups) for the improvement reconstruction for the dominant and nondominant limbs.
of QD on the ACL-reconstructed knees. Future studies are needed to clarify this issue.
The decision on the above frequencies was based on the During the 8 weeks of CEE we did not monitor the training
notion that any exercise program must be performed for a velocity between the two experimental groups, and did not
sufficient duration of weeks and days per week to allow the change the mode of the program. On the other hand, it does
muscle-specific biochemical, mitochondrial, and neurological not seem to be an obvious relationship across studies be-
adaptations to reach a steady state (more than 4 to 5 weeks, 3 tween the mode of exercise program (training velocity,
to 5 days per week).43,44 intensity, duration) and the magnitude of CE.14
Our 8-week CEE program combined with the ACL tradi- However, the training procedures employed in the study
tional rehabilitation program statistically minimized QD in supported a clinically applicable and practical approach,
both experimental groups compared with the control one. though; no exercise progression throughout the training
The results confirm previous findings that quadriceps im- period was provided.
provements were greater for ACL-reconstructed patients who However, as no previous studies have measured CEE in
followed 3 days per week CEE rather than the control one.40,41 specific contraction velocities or exercise modes, it felt logical
However, in our study no statistical results were found to start with a nonprogressive standard exercise for first
between the two experimental groups. From rehabilitation establishing its effectiveness in ACL patients.
perspective this would appear logical that a supplementary Finally, we did not determine the long-term effects of CEE
exercise program attached to the classic rehabilitation pro- following the ACL reconstruction. Thus, further research is
gram is more effective and is more likely to minimize QD, required on this concept.

The Journal of Knee Surgery Vol. 26 No. 1/2013

 Cross-Exercise after ACL Reconstruction Papandreou et al. 57

Conclusion strength after reconstruction using an autogenous patellar tendon

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