Knee flexor strength and symmetry vary by device, body position and angle of assessment following ACL reconstruction with hamstring grafts at long‐term follow‐up

Abstract Purpose Persistent deficits in knee flexor strength following harvest of semitendinosus and gracilis for anterior cruciate ligament reconstruction are inconsistent in the literature. Variation in methodology, including measuring torque at higher knee flexion angles may partially explain these discrepant findings. The objective of this study was to determine whether positioning (seated vs supine), consideration of peak or joint‐angle‐specific torque or device (Isokinetic Dynamometer vs NordBord Hamstring Dynamometer) impact the magnitude of knee flexor strength differences between limbs. Methods Participants ( n = 31, 44.2 ± 10.7 years,) who were at 14 ± 4.4 years follow‐up for unilateral ACL reconstruction with semitendinosus/gracilis grafts completed the ACL Quality of Life outcome and an assessment including isokinetic concentric knee extensor and flexor strength in seated and supine with peak torque and torque at 60° (T60) and 75° (T75) knee flexion measured, followed by an eccentric Nordic Hamstring Curl. Results Isokinetic concentric knee flexor torque was reduced in supine relative to seated, on the reconstructed limb against the unaffected, and at higher degrees of knee flexion relative to peak torque (T60 and T75 against peak torque). Limb symmetry varied by methodology ( F (6,204) = 8.506, p = 0.001) with reduced symmetry in supine T75 against all measures (71.1 ± 16.5%, p < 0.05), supine T60 against seated peak torque (82.7 ± 14.2%, p < 0.05), and the NordBord was lower than seated peak torque that was not statistically significant (83.9 ± 12.8%, n.s.). Knee extensor peak ( r 2 = 0.167 ( F (1,27) = 5.3, p = 0.03) and Nordic curl eccentric torque ( r 2 = 0.267, F (2,26) = 4.736, p = 0.02) were predictors of ACL‐QoL score, although a combined model did not improve over Nordic torque alone. Conclusion Limb symmetry cannot be assumed in clinical practice across differing assessment methods for knee flexor strength as deficits are greatest in the supine position with torque measured at 75° knee flexion. Isokinetic knee extensor and eccentric knee flexor torque during the Nordic hamstring curl were predictors of ACL‐QoL scoring and should be considered alongside patient‐reported outcomes for patients following ACL reconstruction with hamstring grafts. Level of evidence Level IV