The Effect of a Modified Perturbation Training on Muscle Activation Pattern and Function in ACL Deficient Patients

Document Type : Original Article


1 Department of Physiotherapy, Faculty of Rehabilitation Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

2 Department of Physiotherapy, Faculty of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.

3 Research Center, Faculty of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.


Background and Objective: A lesion of the anterior cruciate ligament (ACL) is a major trauma of the knee. Neuromuscular control is believed to be a critical factor in dynamic knee stability in ACL deficient (ACLD) patients. Neuromuscular training programs (in particular perturbation training) are increasingly integrated into clinical practice for ACL lesion rehabilitation. The purpose of this study was to investigate the effect of the modified perturbation training on neuromuscular control system and functional improvement in ACLD.
Subjects and Methods: 10 professional male athletes with  an average of 6.7±3.19 months after their unilateral ACL rupture
participated in this study. Surface Electromyographic (EMG) data were recorded during a cross hop task, from the rectus femoris, vastus medialis, medial head of the gastrocnemius, biceps femoris and gluteus maximus muscles. Muscle activation patterns before and after 10 sessions of perturbation training were compared. Treatment outcome was determined from scores of questionnaires and functional tests.
Results: Scores of IKDC subjective questionnaire and functional tests were significantly improved (P<0.05). Muscle activation patterns were modified. The significant earlier onset and late peak of the rectus femoris resulted in the longer duration from onset-to-peak activity in both of the involved and non involved limbs (P<0.05).
Conclusion: Perturbation training has a central effect that modifies neuromuscular control system through the change in feed-forward control for ACL deficient patients. Rectus femoris activation is not harmful to ACL and causes a protective effect. Optimum activity of this muscle is important for ACL injury prevention and rehabilitation.
Sci Med J 2012;10(6):615-627


1-Williams GN, Chmielewski T, Rudolph K, Buchanan TS, Snyder-Mackler L. Dynamic knee stability: Current theory and implications for clinicians and scientists. J Orthop Sports Phys Ther. 2001; 31: 546-66.
2-Houck JR, Wilding GE, Gupta R, De Haven KE, Maloney M. Analysis of EMG patterns of control subjects and subjects with ACL deficiency during an unanticipated walking cut task. Gait Posture. 2007; 25: 628-38.
3-Doorenbosch CA, Harlaar J. A clinically applicable EMG-force model to quantify active stabilization of the knee after a lesion of the anterior cruciate ligament. Clin Biomech (Bristol, Avon). 2003; 18: 142-9.
4-Zimny ML, Schutte M, Dabezies E. Mechanoreceptors in the human anterior cruciate ligament. Anat Rec. 1986; 214: 204-9.
5-Johansson H, Sjolander P, Sojka P. A sensory role for the cruciate ligaments. Clin Orthop Relat Res. 1991; 268: 161-78.
6-Shultz SJ, Carcia CR, Perrin DH. Knee joint laxity affects muscle activation patterns in the healthy knee. J Electromyogr Kinesiol. 2004; 14: 475-83.
7-Li G, Rudy TW, Sakane M, Kanamori A, Ma CB, Woo SL. The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL. J Biomech. 1999; 32: 395-400.
8-Solomonow M, Baratta R, Zhou BH, Shoji H, Bose W, Beck C, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987; 15: 207-13.
9-Torzilli PA, Deng X, Warren RF. The effect of joint-compressive load and quadriceps muscle force on knee motion in the intact and anterior cruciate ligament-sectioned knee. Am J Sports Med. 1994; 22: 105-12.
10-Rudolph KS, Axe MJ, Buchanan TS, Scholz JP, Snyder-Mackler L. Dynamic stability in the anterior cruciate ligament deficient knee. Knee Surg Sports Traumatol Arthrosc. 2001; 9: 62-71.
11-Williams GN, Barrance PJ, Snyder-Mackler L, Axe MJ, Buchanan TS. Specificity of muscle action after anterior cruciate ligament injury. J Orthop Res. 2003; 21: 1131-7.
12-Eastlack ME, Axe MJ, Snyder-Mackler L. Laxity, instability, and functional outcome after ACL injury: Copers versus noncopers. Med Sci Sports Exerc. 1999; 31: 210-5.
13-Boerboom AL, Hof AL, Halbertsma JP, van Raaij JJ, Schenk W, Diercks RL, et al. Atypical hamstrings electromyographic activity as a compensatory mechanism in anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc. 2001; 9: 211-6.
14-Fitzgerald GK, Axe MJ, Snyder-Mackler L. Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals. J Orthop Sports Phys Ther.  2000; 30: 194-203.
15-Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Phys Ther. 2000; 80: 128-40.
16-Chmielewski TL, Rudolph KS, Snyder-Mackler L. Development of dynamic knee stability after acute ACL injury. J Electromyogr Kinesiol. 2002; 12: 267-74.
17-Chmielewski TL, Hurd WJ, Rudolph KS, Axe MJ, Snyder-Mackler L. Perturbation training improves knee kinematics and reduces muscle co-contraction after complete unilateral anterior cruciate ligament rupture. Phys Ther. 2005; 85: 740-9.
18-Alkjaer T, Simonsen EB, Peter Magnusson SP, Aagaard H, Dyhre-Poulsen P. Differences in the movement pattern of a forward lunge in two types of anterior cruciate ligament deficient patients: Copers and non-copers. Clin Biomech (Bristol, Avon). 2002; 17: 586-93.
19-Berchuck M, Andriacchi TP, Bach BR, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am. 1990; 72: 871-7.
20-Rainoldi A, Melchiorri G, Caruso I. A method for positioning electrodes during surface EMG recordings in lower limb muscles. J Neurosci Methods. 2004; 134: 37-43.
21-Bloem BR, Allum JH, Carpenter MG, Honegger F. Is lower leg proprioception essential for triggering human automatic postural responses?. Exp Brain Res. 2000; 130: 375-91.
22-Soderberg GL, Knutson LM. A guide for use and interpretation of kinesiologic electromyographic data. Phys Ther. 2000; 80: 485-98.
23-Leinonen V, Kankaanpaa M, Airaksinen O, Hanninen O. Back and hip extensor activities during trunk flexion/extension: Effects of low back pain and rehabilitation. Arch Phys Med Rehabil. 2000; 81: 32-7.
24-Soderberg GL, Cook TM, Rider SC, Stephenitch BL. Electromyographic activity of selected leg musculature in subjects with normal and chronically sprained ankles performing on a BAPS board. Phys Ther. 1991; 71: 514-22.
25-Kavanagh JJ, Menz HB. Accelerometry: a technique for quantifying movement patterns during walking. Gait Posture. 2008; 28: 1-15.
26-Blackburn JT, Riemann BL, Myers JB, Lephart SM. Kinematic analysis of the hip and trunk during bilateral stance on firm, foam, and multiaxial support surfaces. Clin Biomech (Bristol, Avon). 2003; 18: 655-61.
27-Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, et al. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med.  2001; 29: 600-13.
28-Rossi MJ, Lubowitz JH, Guttmann D. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med. 2002; 30: 152.
29-Fitzgerald GK, Lephart SM, Hwang JH, Wainner RS. Hop tests as predictors of dynamic knee stability. J Orthop Sports Phys Ther. 2001; 31: 588-97.
30-Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2000; 8: 76-82.
31-Rudolph KS, Axe MJ, Snyder-Mackler L. Dynamic stability after ACL injury: Who can hop?. Knee Surg Sports Traumatol Arthrosc. 2000; 8: 262-9.
32-Ingersoll CD, Grindstaff TL, Pietrosimone BG, Hart JM. Neuromuscular consequences of anterior cruciate ligament injury. Clin Sports Med. 2008; 27: 383-404.
33-Kapreli E, Athanasopoulos S. The anterior cruciate ligament deficiency as a model of brain plasticity. Med Hypotheses. 2006; 67: 645-50.
34-Medina JM, Valovich McLeod TC, Howell SK, Kingma JJ. Timing of neuromuscular activation of the quadriceps and hamstrings prior to landing in high school male athletes, female athletes, and female non-athletes. J Electromyogr Kinesiol. 2008; 18: 591-7.
35-Matsumoto T, Tsumura N, Kubo S, Shiba R, Kurosaka M, Yoshiya S. Influence of hip position on knee flexion angle in patients undergoing total knee arthroplasty. J Arthroplasty. 2005; 20: 669-73.
36-Hurd WJ, Chmielewski TL, Snyder-Mackler L. Perturbation-enhanced neuromuscular training alters muscle activity in female athletes. Knee Surg Sports Traumatol Arthrosc. 2006; 14: 60-9.
37-Button K, Van Deursen R, Price P. Classification of functional recovery of anterior cruciate ligament copers, non-copers, and adapters. Br J Sports Med. 2006; 40: 853-9.
38-Alkjaer T, Simonsen EB, Jorgensen U, Dyhre-Poulsen P. Evaluation of the walking pattern in two types of patients with anterior cruciate ligament deficiency: Copers and non-copers. Eur J Appl Physiol. 2003; 89: 301-8.
39-Rudolph KS, Eastlack ME, Axe MJ, Snyder-Mackler L. 1998 Basmajian Student Award Paper: Movement patterns after anterior cruciate ligament injury: A comparison of patients who compensate well for the injury and those who require operative stabilization. J Electromyogr Kinesiol. 1998; 8: 349-62.
40-Urabe Y, Kobayashi R, Sumida S, Tanaka K, Yoshida N, Nishiwaki GA, et al. Electromyographic analysis of the knee during jump landing in male and female athletes. Knee. 2005; 12: 129-34.
41-Hurd WJ, Snyder-Mackler L. Knee instability after acute ACL rupture affects movement patterns during the mid-stance phase of gait. J Orthop Res. 2007; 25: 1369-77.
42-Vuillerme N, Nougier V, Teasdale N. Effects of lower limbs muscular fatigue on anticipatory postural adjustments during arm motions in humans. J Sports Med Phys Fitness. 2002; 42: 289-94.
43-Aagaard P. Training-induced changes in neural function. Exerc Sport Sci Rev. 2003; 31: 61-7.
44-Santos MJ, Aruin AS. Role of lateral muscles and body orientation in feedforward postural control. Exp Brain Res. 2008; 184: 547-59.
45-Papadonikolakis A, Cooper L, Stergiou N, Georgoulis AD, Soucacos PN. Compensatory mechanisms in anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc. 2003; 11: 235-43.
46-Ernst GP, Saliba E, Diduch DR, Hurwitz SR, Ball DW. Lower extremity compensations following anterior cruciate ligament reconstruction. Phys Ther. 2000; 80: 251-60.
47-Bodor M. Quadriceps protects the anterior cruciate ligament. J Orthop Res. 2001; 19: 629-33.
48-Aune AK, Cawley PW, Ekeland A. Quadriceps muscle contraction protects the anterior cruciate ligament during anterior tibial translation. Am J Sports Med. 1997; 25: 187-90.
49-Aune AK, Nordsletten L, Ekeland A. Structural capacity of the knee to anterior cruciate ligament failure during quadriceps contraction: An in vivo study in the rat. J Biomech. 1996; 29: 891-7.
50-Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE, Andrews JR. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc. 1998; 30: 556-69.
51-Herrington L, Fowler E. A systematic literature review to investigate if we identify those patients who can cope with anterior cruciate ligament deficiency. Knee. 2006; 13: 260-5.