The Journal of Bone and Joint Surgery (American). 2007;89:559-570.
doi:10.2106/JBJS.F.00385
© 2007 The Journal of Bone and Joint Surgery, Inc.
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Effects of Early Progressive Eccentric Exercise on Muscle Structure After Anterior Cruciate Ligament Reconstruction

J. Parry Gerber, PT, PhD, SCS, ATC1, Robin L. Marcus, PhD, PT, OCS1, Leland E. Dibble, PhD, PT, ATC1, Patrick E. Greis, MD2, Robert T. Burks, MD2 and Paul C. LaStayo, PhD, PT, CHT1

1 Division of Physical Therapy (J.P.G., R.L.M., L.E.D., and P.C.L.), University of Utah, 520 Wakara Way, Salt Lake City, UT 84108. E-mail address for J.P. Gerber: J.Parry.Gerber{at}utah.edu
2 Department of Orthopedics, University of Utah, 590 Wakara Way, Room 58, Salt Lake City, UT 84108

Investigation performed at the University of Utah, Salt Lake City, Utah

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the Orthopaedic Section of the American Physical Therapy Association. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: Thigh muscle atrophy is a major impairment that occurs early after reconstruction of the anterior cruciate ligament and persists for several years. Eccentric resistance training has the potential to induce considerable gains in muscle size and strength that could prove beneficial during postoperative rehabilitation. The purpose of this study was to evaluate the effects of progressive eccentric exercise on thigh muscle structure following reconstruction of the anterior cruciate ligament.

Methods: Beginning three weeks after reconstruction of the anterior cruciate ligament, forty patients were randomly assigned to a program involving either twelve weeks of eccentric exercises or a standard rehabilitation protocol. Patients were matched by surgical procedure, sex, and age. The final series consisted of two cohorts of twenty patients each who had been treated with one of two types of graft (semitendinosus-gracilis or bone-patellar tendon-bone), with ten patients treated with each of the two rehabilitation protocols in each graft cohort. To evaluate changes in muscle structure, magnetic resonance images of the involved and uninvolved thighs were acquired before and after training. The volume and peak cross-sectional area of the quadriceps, hamstrings, and gracilis and the distal portion of the gluteus maximus were calculated from these images.

Results: The volume and peak cross-sectional area of the quadriceps and gluteus maximus, in both the involved and the uninvolved thighs and in the patients treated with each type of graft, improved significantly more in the eccentric-exercise group (p < 0.001). The magnitude of the volume change was more than twofold greater in that group. No significant differences in any hamstring or gracilis structural measurements were observed between the rehabilitation groups. However, the volume and peak cross-sectional area of the gracilis were markedly reduced, compared with the pretraining values, in the patients who had undergone reconstruction with the semitendinosus-gracilis graft.

Conclusions: Eccentric resistance training implemented three weeks after reconstruction of the anterior cruciate ligament can induce structural changes in the quadriceps and gluteus maximus that greatly exceed those achieved with a standard rehabilitation protocol. The success of this intervention can be attributed to the gradual and progressive exposure to negative work through eccentric exercise, ultimately leading to production of high muscle force.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.


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