Serial Changes in Knee Muscle Strength and Functional Performance After Anterior Cruciate Ligament Reconstruction: A Retrospective Cohort Study of 107 Patients

Background and Objectives: Anterior cruciate ligament (ACL) reconstruction (ACLR) is widely performed to restore knee stability and facilitate return to activity. However, recovery of muscle strength, balance, functional performance, and patient-reported outcomes does not occur uniformly over time. The longitudinal recovery trajectory across various functional areas during the first year after ACLR remains insufficiently characterized. Materials and Methods: We included 107 patients who underwent isolated unilateral ACLR using a hamstring autograft. Isokinetic knee extensor and flexor strength, postural stability, Y-Balance Test (YBT) performance, and subjective knee function scores were assessed post-injury (approximately six weeks after ACL injury and prior to ACLR) and at 3, 6, and 12 months postoperatively. All patients followed a standardized postoperative rehabilitation protocol. Results: Knee extensor strength deficit worsened at 3 months and remained present at 12 months. In contrast, knee flexor strength deficit decreased progressively and reached near-symmetrical values by 12 months. Sway path length decreased significantly over time in both limbs. In the operated limb, improvements plateaued after 6 months, and limb symmetry indices approached symmetry by 12 months. YBT limb symmetry indices demonstrated a non-linear recovery pattern. Anterior, posterolateral, and composite scores decreased at 3 months, recovered to post-injury levels by 6 months, and showed significant improvement at 12 months. Posteromedial reach did not decline at 3 months and improved significantly only at 12 months. Subjective knee function scores (Lysholm and IKDC) did not differ significantly between post-injury and 3-month assessments, but improved significantly from 6 months onward. Tegner activity scores gradually increased and returned to pre-injury levels by 12 months. Conclusions: Recovery after ACLR is prolonged and non-synchronous. Quadricep strength remains incompletely restored at 12 months, whereas hamstring strength recovers more favorably. Balance, functional performance, and subjective outcomes improve mainly after 6 months. These findings support the need for prolonged rehabilitation and serial, multidimensional functional assessments beyond time-based criteria.