Postural Control and Weight Distribution of Men with Anterior Cruciate Ligament Reconstruction during Quiet Standing

Document Type : Original research papers


1 Department of Exercise Physiology, Faculty of Sport Sciences, Alzahra University, Tehran, Iran

2 Department of Sports Physiology and Pathology, Faculty of Sport Sciences, Arak University, Arak, Iran.

3 Department of Mechanical Enginnering, Jundi-Shapur University of Technology, Dezful,Iran.


Anterior cruciate ligament reconstruction (ACLR) has been considered one of the common treatments for ACL injury. Decrease in the proprioceptive function following ACLR, which may remain between 2 and 3 years after the surgery, provides the possibility of re-injury. Therefore, this study aims to investigate the postural control, weight distribution, and center of pressure (COP) Symmetry Index in individuals with ACLR during quiet standing, in open and closed eyes conditions, compared to healthy people. In the present study, 12 men with right ACLR and 12 healthy men were recruited as participants. Participants stood barefoot on the two force plates. Each foot was placed on one of the 2 platforms. Postural control was assessed during quiet standing in two conditions (open and closed eyes conditions). The positions of COP in antero-posterior and medio-lateral directions are detected under the right and left foot separately and also as net. Postural sway quantified based on five parameters included the amplitude (AMP), total excursions (TOTEX), mean velocity (MVELO), standard deviation (SD), and 95% confidence ellipse area (AREACE). Weight distribution percentage on the lower limbs and COP Symmetry Index in antero-posterior direction were also calculated. The results showed that the COP parameters in some investigated parameters (TOTEXap, SDap, AREACE, AMPap, TOTEXml) were higher in individuals with ACLR than in the healthy group (P<0.05). There was no difference between the two groups regarding the Symmetry Index in the eyes open and closed conditions (P>0.05). Weight distribution, in eyes open condition, in ACLR group on the operated limb is more than that in healthy people (P<0.05).We concluded that individuals with ACLR has a poor postural control in anteroposterior (AP) and mediolateral (ML) directions during quiet standing. The Symmetry Index was the same in both groups. In contrast to the able-bodied participants, individuals with ACLR bear more body weight on the operated limb than on the non- operated limb.


Main Subjects

  1. Friemert B, Franke S, Gollhofer A, Claes L, Faist M. Group I afferent pathway contributes to functional knee stability. Journal of neurophysiology. 2010;103(2):616-622.
  2. Bartels T, Brehme K, Pyschik M, Pollak R, Schaffrath N, Schulze S, Delank KS, Laudner K, Schwesig R. Postural stability and regulation before and after anterior cruciate ligament reconstruction–A two years longitudinal study. Physical Therapy in Sport. 2019;38:49-58.
  3. Diermann N, Schumacher T, Schanz S, Raschke MJ, Petersen W, Zantop T. Rotational instability of the knee: internal tibial rotation under a simulated pivot shift test. Archives of Orthopaedic and Trauma Surgery. 2009;129:353-358.
  4. Lehmann T, Paschen L, Baumeister J. Single-leg assessment of postural stability after anterior cruciate ligament injury: a systematic review and meta-analysis. Sports medicine-open. 2017;3(1):32.
  5. Ageberg E, Roberts D, Holmström E, Fridén T. Balance in single-limb stance in patients with anterior cruciate ligament injury: relation to knee laxity, proprioception, muscle strength, and subjective function. The American journal of sports medicine. 2005;33(10):1527-1237.
  6. Denti M, Randelli P, Lo Vetere D, Moioli M, Bagnoli I, Cawley PW. Motor control performance in the lower extremity: normals vs. anterior cruciate ligament reconstructed knees 5–8 years from the index surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2000;8(5):296-300.
  7. Cohen J. Statistical power analysis for the behavioral sciences (2nd edition). Hillsdale: LawrenceErlbaum Associates; 1988.
  8. Fridén T, Roberts D, Zätterström R, Lindstrand A, Moritz U. Proprioception in the nearly extended knee: measurements of position and movement in healthy individuals and in symptomatic anterior cruciate ligament injured patients. Knee Surgery, Sports Traumatology, Arthroscopy. 1996;4:217-224.
  9. Fleming JD, Ritzmann R, Centner C. Effect of an anterior cruciate ligament rupture on knee proprioception within 2 Years after conservative and operative treatment: A systematic review with meta-analysis. Sports Medicine. 2022;1:1-12.
  10. Staples JR, Schafer KA, Smith MV, Motley J, Halstead M, Blackman A, Haas A, Steger-May K, Matava MJ, Wright RW, Brophy RH. Decreased postural control in patients undergoing anterior cruciate ligament reconstruction compared to healthy controls. Journal of Sport Rehabilitation. 2019;29(7):920-925.
  11. Moussa AZ, Zouita S, Dziri C, Salah FB. Single-leg assessment of postural stability and knee functional outcome two years after anterior cruciate ligament reconstruction. Annals of physical and rehabilitation medicine. 2009;52(6):475-584.
  12. Pahnabi G, Akbari M, Ansari NN, Mardani M, Ahmadi M, Rostami M. Comparison of the postural control between football players following ACL reconstruction and healthy subjects. Medical journal of the Islamic Republic of Iran. 2014;28:101.
  13. Henriksson M, Ledin T, Good L. Postural control after anterior cruciate ligament reconstruction and functional rehabilitation. The American journal of sports medicine. 2001;29(3):359-566.
  14. Sell TC. An examination, correlation, and comparison of static and dynamic measures of postural stability in healthy, physically active adults. Physical Therapy in Sport. 2012;13(2):80-86.
  15. Heinert B, Willett K, Kernozek TW. Influence of anterior cruciate ligament reconstruction on dynamic postural control. International journal of sports physical therapy. 2018;13(3):432.
  16. Mochizuki L, Duarte M, Amadio AC, Zatsiorsky VM, Latash ML. Changes in postural sway and its fractions in conditions of postural instability. Journal of applied biomechanics. 2006;22(1):51-60.
  17. Bonfim TR, Paccola CA, Barela JA. Proprioceptive and behavior impairments in individuals with anterior cruciate ligament reconstructed knees. Archives of physical medicine and rehabilitation. 2003;84(8):1217-1223.
  18. Swanenburg J, de Bruin ED, Favero K, Uebelhart D, Mulder T. The reliability of postural balance measures in single and dual tasking in elderly fallers and non-fallers. BMC Musculoskelet Disord. 2008;9:162;1-10.
  19. Palmieri RM, Ingersoll CD, Cordova ML, Kinzey SJ, Stone MB, Krause BA. The effect of a simulated knee joint effusion on postural control in healthy subjects. Archives of physical medicine and rehabilitation. 2003;84(7):1076-1079.
  20. Winter DA. Human balance and posture control during standing and walking. Gait & posture. 1995;3(4):193-214.
  21. Winter, D.A. Biomechanics and Motor Control of Human Movement; JohnWiley and Sons, Inc.: Hoboken, NJ, USA, 2009.
  22. Prieto TE, Myklebust JB, Hoffmann RG, Lovett EG, Myklebust BM. Measures of postural steadiness: differences between healthy young and elderly adults. IEEE Transactions on biomedical engineering. 1996;43(9):956-966.
  23. Winter DA, Patla AE, Prince F, Ishac M, Gielo-Perczak K. Stiffness control of balance in quiet standing. Journal of neurophysiology. 1998;80(3):1211-1221.
  24. Karlsson A, Frykberg G. Correlations between force plate measures for assessment of balance. Clinical Biomechanics. 2000;15(5):365-359.
  25. Gage WH, Winter DA, Frank JS, Adkin AL. Kinematic and kinetic validity of the inverted pendulum model in quiet standing. Gait & posture. 2004;19(2):124-32.
  26. Kleipool RP, Blankevoort L. The relation between geometry and function of the ankle joint complex: a biomechanical review. Knee surgery, sports traumatology, arthroscopy. 2010;18:618-627.
  27. Winter DA, Patla AE, Ishac M, Gage WH. Motor mechanisms of balance during quiet standing. Journal of electromyography and kinesiology. 2003;13(1):49-56.
  28. Jafarnezhadgero AA, Shad MM, Majlesi M. Effect of foot orthoses on the medial longitudinal arch in children with flexible flatfoot deformity: A three-dimensional moment analysis. Gait & posture. 2017;55:75-80.
  29. Rougier PR. Relative contribution of the pressure variations under the feet and body weight distribution over both legs in the control of upright stance. Journal of Biomechanics. 2007;40(11):2477-2482.
  30. Soangra R, Lockhart TE. Determination of stabilogram diffusion analysis coefficients and invariant density analysis parameters to understand postural stability associated with standing on anti-fatigue mats. Biomedical sciences instrumentation. 2012;48:415-422.
  31. Brauer SG, Burns YR, Galley P. A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2000;55(8):469-476.
  32. Dauty M, Collon S, Dubois C. Change in posture control after recent knee anterior cruciate ligament reconstruction?. Clinical physiology and functional imaging. 2010;30(3):187-191.
  33. Fernandes TL, Felix EC, Bessa F, Luna N, Sugimoto D, Greve JM, Hernandez AJ. Evaluation of static and dynamic balance in athletes with anterior cruciate ligament injury–A controlled study. Clinics. 2016;71(8):425-429.
  34. Mohammadi F, Salavati M, Akhbari B, Mazaheri M, Khorrami M, Negahban H. Static and dynamic postural control in competitive athletes after anterior cruciate ligament reconstruction and controls. Knee surgery, sports traumatology, arthroscopy. 2012;20(8):1603-1610.
  35. Parus K, Lisiński P, Huber J. Body balance control deficiencies following ACL reconstruction combined with medial meniscus suture. A preliminary report. Orthopaedics & Traumatology: Surgery & Research. 2015;101(7):807-810.
  36. Lehmann T, Büchel D, Cockcroft J, Louw Q, Baumeister J. Modulations of inter-hemispherical phase coupling in human single leg stance. Neuroscience. 2020;430:63-72.
  37. Jiganti MR, Meyer BC, Chang E, Romanelli DA, An YW. Altered cortical activation after anterior cruciate ligament reconstruction during single‐leg balance task. Translational Sports Medicine. 2020;3(5):496-503.
  38. Bartels T, Brehme K, Pyschik M, Schulze S, Delank KS, Fieseler G, Laudner KG, Hermassi S, Schwesig R. Pre-and postoperative postural regulation following anterior cruciate ligament reconstruction. Journal of exercise rehabilitation. 2018;14(1):143-151.
  39. Mansfield A, Inness EL. Force plate assessment of quiet standing balance control: perspectives on clinical application within stroke rehabilitation. Rehabilitation Process and Outcome. 2015;4:RPO-S20363.
  40. Lephart E, Fu FH. Proprioception and neuromuscular control in joint stability. Percept Motor Skill. 2001;92(1):319–20.
  41. Jafarnezhadgero AA, Pourrahimghoroghchi A, Darvishani MA, Aali S, Dionisio VC. Analysis of ground reaction forces and muscle activity in individuals with anterior cruciate ligament reconstruction during different running strike patterns. Gait & Posture. 2021;90:204-209.
  42. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine. 2014;48(21):1543-1552.
  43. Cinque ME, Dornan GJ, Chahla J, Moatshe G, LaPrade RF. High rates of osteoarthritis develop after anterior cruciate ligament surgery: an analysis of 4108 patients. The American journal of sports medicine. 2018;46(8):2011-2019.
  44. Pourrahim Ghouroghchi A, Jafarnezhadgero A, Abdollahpour Darvishani M. Determination of Selected Lower Limb Muscles Electromyography Frequency Spectrum in Male Soccer Players with ACL Injury during Three Running Patterns. Journal of Advanced Sport Technology. 2022;6(2):1-9.
  45. Rougier PR, Genthon N. Dynamical assessment of weight-bearing asymmetry during upright quiet stance in humans. Gait & posture. 2009;29(3):437-443.
  46. Negahban H, Ahmadi P, Salehi R, Mehravar M, Goharpey S. Attentional demands of postural control during single leg stance in patients with anterior cruciate ligament reconstruction. Neuroscience Letters. 2013;556:118-123.
  47. Mohammadi-Rad S, Salavati M, Ebrahimi-Takamjani I et al. Dual-tasking effectson dynamic postural stability in athletes with and without anterior cruciate ligament reconstruction. Journal of Sport Rehabilitation. 2016; 25(4):324–329.
  48. Kubisz L, Werner H, Bosek M, Weiss W. Posture stability evaluation using static posturography in patients after cruciate ligament reconstruction. Acta Physica Polonica A. 2011;119(6A):957-960.
  49. Palm HG, Schlumpberger S, Riesner HJ, Friemert B, Lang P. Influence of anterior cruciate reconstruction on postural stability: a pre-and postoperative comparison. Der Unfallchirurg. 2015;118(6):527-534.
  50. Bartels T, Brehme K, Pyschik M, Pollak R, Schaffrath N, Schulze S, Delank KS, Laudner K, Schwesig R. Postural stability and regulation before and after anterior cruciate ligament reconstruction–A two years longitudinal study. Physical Therapy in Sport. 2019;38:49-58.
  51. Howells B, Ardern C, Webster K, Feller J, Whitehead T, Bryant A, Clark R. Postural control and the influence of a secondary task in people with anterior cruciate ligament reconstructed knees. Journal of Science and Medicine in Sport. 2012;15:S354-5.
  52. Lepley AS, Grooms DR, Burland JP, Davi SM, Kinsella-Shaw JM, Lepley LK. Quadriceps muscle function following anterior cruciate ligament reconstruction: systemic differences in neural and morphological characteristics. Experimental brain research. 2019;237:1267-1278.
  53. Mazaheri M, Negahban H, Soltani M, Mehravar M, Tajali S, Hessam M, Salavati M, Kingma I. Effects of narrow-base walking and dual tasking on gait spatiotemporal characteristics in anterior cruciate ligament-injured adults compared to healthy adults. Knee Surgery, Sports Traumatology, Arthroscopy. 2017;25:2528-2535.
  54. Lehmann T, Büchel D, Mouton C, Gokeler A, Seil R, Baumeister J. Functional cortical connectivity related to postural control in patients six weeks after anterior cruciate ligament reconstruction. Frontiers in Human Neuroscience. 2021;15:655116.
  55. Okuda K, Abe N, Katayama Y, Senda M, Kuroda T, Inoue H. Effect of vision on postural sway in anterior cruciate ligament injured knees. Journal of Orthopaedic Science. 2005;10(3):277-283.
  56. Kapreli E, Athanasopoulos S, Gliatis J, Papathanasiou M, Peeters R, Strimpakos N, Van Hecke P, Gouliamos A, Sunaert S. Anterior cruciate ligament deficiency causes brain plasticity: a functional MRI study. The American journal of sports medicine. 2009;37(12):2419-2426.
  57. Dauty M, Collon S, Dubois C. Change in posture control after recent knee anterior cruciate ligament reconstruction?. Clinical physiology and functional imaging. 2010;30(3):187-191.
  58. Konishi YU. ACL repair might induce further abnormality of gamma loop in the intact side of the quadriceps femoris. International journal of sports medicine. 2011;32(04):292-296.
  59. Piontek T,Ciemniewska-Gorzela K, Szulc A, Pyda A, Dudzinski W, Hejna R, ChirurgiaNarzadów Ruchu i Ortopedia Polska. 2009;74, 353. (in Polish).
  60. Ruhe A, Fejer R, Walker B. Center of pressure excursion as a measure of balance performance in patients with non-specific low back pain compared to healthy controls: a systematic review of the literature. European Spine Journal. 2011;20:358-368.
  61. Hirata RP, Arendt-Nielsen L, Shiozawa S, Graven-Nielsen T. Experimental knee pain impairs postural stability during quiet stance but not after perturbations. European journal of applied physiology. 2012;112:2511-2521.
  62. Stodółka J, Blach W, Vodicar J, Maćkała K. The characteristics of feet center of pressure trajectory during quiet standing. Applied Sciences. 2020;10(8):2940.
  63. Ageberg E, Roberts D, Holmström E, Fridén T. Balance in single-limb stance in healthy subjects–reliability of testing procedure and the effect of short-duration sub-maximal cycling. BMC Musculoskeletal disorders. 2003;4:1-6.
  64. Lin WH, Liu YF, Hsieh CC, Lee AJ. Ankle eversion to inversion strength ratio and static balance control in the dominant and non-dominant limbs of young adults. Journal of Science and Medicine in Sport. 2009;12(1):42-49.
  65. Barone R, Macaluso F, Traina M, Leonardi V, Farina F, Di Felice V. Soccer players have a better standing balance in nondominant one-legged stance. Open access journal of sports medicine. 2010:1-6.
  66. Reider B, Arcand MA, Diehl LH, Mroczek K, Abulencia A, Stroud CC, Palm M, Gilbertson J, Staszak P. Proprioception of the knee before and after anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2003;19(1):2-12.
  67. Hoffman M, Schrader J, Koceja D. An investigation of postural control in postoperative anterior cruciate ligament reconstruction patients. Journal of Athletic Training. 1999;34(2):130-136.