The Knee 16 (2009) 387391

Contents lists available at ScienceDirect

The Knee

Correlation between proprioception, muscle strength, knee laxity, and dynamic

standing balance in patients with chronic anterior cruciate ligament deciency
Hung-Maan Lee a, Cheng-Kung Cheng b, Jiann-Jong Liau c,d,
a

Department of Orthopaedic Surgery, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
Institute of Biomedical Engineering, National Yang Ming University, Taipei, Taiwan
School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
d
Research and Development Center, United Orthopedic Corporation, Hsinchu, Taiwan
b
c

a r t i c l e

i n f o

Article history:
Received 18 March 2008
Received in revised form 23 January 2009
Accepted 24 January 2009
Keywords:
Proprioception
Muscle strength
Dynamic stance balance
Anterior cruciate ligament (ACL) deciency

a b s t r a c t
Proprioception and muscle strength are both reported to inuence single-limb stance balance in patients
with chronic anterior cruciate ligament (ACL) injuries. However, the effects of these parameters on dynamic
stance balance in such patients are currently unknown. This study was undertaken to ascertain whether
proprioception, muscle strength, and knee laxity are correlated with dynamic standing balance in patients
with ACL deciency. Ten young men with unilateral ACL deciency participated in this study. The mean time
interval from the injury to the study was 12.8 months. Knee laxity measurements, passive re-positioning
(PRP) and threshold for detection of passive motion (TTDPM) proprioception tests, quadriceps and
hamstring muscle strength tests, and dynamic single-limb balance tests were performed for both injured and
uninjured limbs. Signicant differences between the injured and uninjured sides were observed for all test
parameters. As independent variables, knee laxity, PRP proprioception, and muscle strength did not correlate
with dynamic standing balance for the injured limb. However, a signicant positive correlation (P b 0.05)
between TTDPM proprioception and dynamic single-limb stance balance was observed for the injured limb.
To improve dynamic single-limb stance balance in patients with ACL injuries, training in TTDPM
proprioceptive ability is recommended as the most important initial approach for such patients.
2009 Elsevier B.V. All rights reserved.

1. Introduction
Injury to the anterior cruciate ligament (ACL) leading to defects in
passive joint stability and disruption of proprioceptive function is a
common occurrence in young athletes [1]. Proprioception, the ability
to sense stimuli arising within the body, includes the capacity to sense
joint position and joint motion [2]. Proprioceptive mechanoreceptors,
such as Rufni endings, Pacinian corpuscles, and Golgi tendon organs,
are present in the ACL [35]. Quick-adapting mechanoreceptors, such
as the Pacinian corpuscles, are thought to mediate the sensation of
joint motion; whereas slow-adapting mechanoreceptors, such as the
Rufni endings and Golgi tendon organs, are thought to mediate the
sensation of joint position [6]. A statistically signicant decrease in
proprioceptive ability in patients with ACL-decient knees has been
observed in several studies [79]. The sensory information derived
from proprioception, as well as from the vestibular and visual systems,
contributes to the maintenance and control of posture and balance in
a particular position or during movement [10]. Any type of dysfunc-

Corresponding author. Research and Development Center, United Orthopedic

Corporation, No. 57, Park Ave 2, Science Park, Hsinchu 300, Taiwan. Tel.: +886 3
5773351; fax: +886 3 5777156.
E-mail address: jjliau@uoc.com.tw (J.-J. Liau).
0968-0160/$ see front matter 2009 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2009.01.006

tion in proprioception, as well as in the vestibular or visual systems,

may, therefore, impair postural control.
Balance requires the continuous adjustment of muscle activity and
joint position to retain the body's center of gravity over the base of
support [11]. Factors with the potential to inuence balance include
muscle fatigue or weakness, age, sex, level of physical activity, and
previous injury to a lower-extremity [12]. Impaired single-limb stance
balance, measured by a force platform, has been reported for
individuals with chronic ACL injuries [1315]. However, relatively
few studies have been performed that examine the relationship
between impaired proprioception and standing balance in these
individuals. Ageberg et al. [16] examined the inuence of knee laxity,
proprioception, and muscle strength on balance in a single-limb
stance in patients with chronic ACL injuries. Stabilometry, including
the amplitude and average speed of the center of pressure movements, for single-limb stance balance was measured on a static force
platform. Their ndings revealed that proprioception and the
strengths of the quadriceps and hamstring muscles signicantly
inuenced the average speed of the center of pressure among women.
Poor proprioception and high muscle strength values reduced the
movement speed of the center of pressure.
The proprioception test can be used to measure either the
threshold for detection of passive motion [16,17] or the sense of
joint repositioning [2,17], while the balance test can be performed

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H.-M. Lee et al. / The Knee 16 (2009) 387391

Table 1
Basic characteristics of 12 participants with chronic ACL injuries.
Patient
number

Sex

Age
(years)

Weight
(kg)

Height
(cm)

Activity
causing
injury

Months
from injury
to testing

Lysholm
score

1
2
3
4
5
6
7
8
9
10
11
12
Mean
SD

M
F
M
M
F
M
M
M
M
M
M
M

24.2
23.3
20.2
21.8
26.6
23.3
21.9
23.1
22.2
25.7
24.2
20.8
23.1
1.8

58
61
60
64
63
67
52
68
62
65
65
61
62.2
4.1

173
162
168
167
155
171
158
171
176
168
172
170
167.6
6.0

Basketball
Jogging
Basketball
Basketball
Basketball
Basketball
Soccer
Basketball
Basketball
Basketball
Basketball
Jogging

13
12
10
12
24
11
12
9
10
16
10
15
12.8
3.9

78
86
81
77
82
77
77
74
69
74
81
77
77.75
4.23

either on a rm stable platform (stabilometry) [16] or on a moveable

or inrm (not xed on the ground) platform (the dynamic test) [2,12].
O'Connell et al. [18] suggested that the use of a postural sway meter
(stabilometry) for predicting function and stability during dynamic
activities in patients with ACL deciency may be inappropriate. The
present study was therefore undertaken to assess the inuence of
knee laxity, proprioception, and muscle strength on dynamic balance
in the single-limb stance for patients with chronic ACL injuries. We
hypothesized that a positive correlation existed between muscle
strength, proprioception, and dynamic balance.

mean height was 167.6 cm (range,155 to 176), and the mean body weight
was 62.2 kg (range, 52 to 67). The mean interval from the time of injury
to the time of testing was 12.8 months (range, 9 to 24). The
characteristics of the participants are given in Table 1; most ACL injuries
(75%) were incurred while playing basketball. All participants signed
informed consent forms, and all tests were approved by the Research
Ethics Committee at our institute (HML). The tests described below were
performed in the following order: (1) knee laxity, (2) proprioception,
(3) dynamic balance, and (4) muscle strength. The test order was selected on the basis of the study of Ageberg et al. [16], and we also believe
each previous test will not inuence the result of the subsequent test.
2.2. Measurement of knee laxity
Anterior displacement of the tibia relative to the femur was measured
using a KT-1000 arthrometer (MEDmetric Corp., San Diego, CA) with a
148 N (30 lb) force. The arthrometer was xed to the limb with the knee
exed at 30. Anterior displacement was recorded in millimeters.

2. Methods
2.1. Participants
Twelve patients, 10 men and two women, participated in this study.
Inclusion criteria were as follows: (1) age between 15 and 30 years;
(2) presence of unilateral, chronic ACL deciency not treated surgically
and without associated lesions on other structures of the knee; and
(3) absence of history of neurological disease or of vestibular or visual
disturbance [16]. The mean age was 23.1 years (range, 20 to 26), the

Fig. 1. Proprioception testing position and apparatus. To simulate passive positioning,

the participant sat in an upright position with the knee exed at 45. The proprioception
test apparatus (PTA) was designed by the authors.

Fig. 2. The systematic and schematic representation of the self-designed, computerized,

balance-testing machine.

H.-M. Lee et al. / The Knee 16 (2009) 387391

Table 2
Mean values with standard deviations and ranges for knee laxity, proprioception,
muscle strength, and dynamic standing balance for 10 male participants with ACL
injuries.
Variable (unit)

Injured side (n = 10)

Uninjured side (n=10) P values Power

Knee laxity (mm)

11.8 2.10 (815)
4.70 1.64 (27)
PRP ()
4.64 1.70 (2.38.6)
3.53 1.30 (2.17.0)
TTDPM ()
3.76 2.60 (0.78.0)
2.61 1.95 (0.65.6)
Quadriceps strength 121.0 32.1 (60168) 155.9 38.8 (88216)
(N m)
Hamstring strength
99.1 22.2 (44122) 122.9 28.8 (63171)
(N m)
H/Q ratio (100%)
82.7 9.7 (6498)
79.4 10.2 (7094)
Tilt angle of balance 6.68 2.28 (2.39.8)
5.41 1.92 (1.97.4)
()

b 0.001
0.001
0.015
b 0.001

1.0
0.35
0.17
0.55

b 0.001

0.50

0.460
b 0.001

0.10
0.25

2.3. Proprioception test

Proprioception was measured with a self-designed apparatus as
described previously [17,19]. In the passive re-positioning (PRP) test,
participants sat on a Con-Trex MJ bed (Con-Trex, Zurich, Switzerland)
with their knee at 45 of exion. A pneumatic compression cuff was
placed on the foot of the tested limb to reduce the contribution of
cutaneous stimuli to the sense of position. The cuff was attached to the
L-shaped arm of the proprioception testing apparatus (PTA) (Fig. 1).
To eliminate visual clues to knee position, all participants were
blindfolded. To eliminate auditory clues to the start of knee exion,
participants wore a set of earphones and listened to white noise
during the test. The PTA rotated the knee along the axis of the joint
toward extension (from 45 exion to extension) or toward exion
(from 45 exion to 90 exion) then passively positioned back to the
starting point (45 exion) at a velocity of 0.5/s. When the subject
felt his or her knee was passively positioned back to the reference
angle (45 of knee exion), he/she ipped a switch. Three test trials
were administered, and the mean absolute differences between the
target and the reproduced angles were used for statistical analyses.
Measurement of the threshold for detection of passive motion
(TTDPM) was performed toward exion and extension from the
starting position with the knee exed at 45. The PTA rotated the knee
at an angular velocity of 0.5/s. The participants were asked to
concentrate on the knee and respond when they felt any sensation
of movement or change in position by ipping a switch. Three trials
were administered, and mean errors were also recorded.
2.4. Dynamic balance test
The dynamic balance test was administered in a self-designed,
computerized, balance-testing apparatus as described previously [19].

389

This apparatus consists of a dynamic platform, A/D converter, selfdesigned software, and a real-time display monitor for visual
biofeedback (Fig. 2). A ball-bearing with small frictional resistance is
located beneath the geometric center of the stance platform. Two
linear variable differential transformers (LVDT), located on the
horizontal plane of the platform, record the prole of positional
information. The tilt angle of the stance platform relative to the
vertical axis can then be calculated. The maximum tilt angle for this
platform is 15 in any direction. During the dynamic balance tests,
participants stood on the affected limb rst. They then stood on the
unaffected limb with the stance foot centered on the platform and
with the contralateral knee in slight exion. Participants wore
suspension harnesses to protect against falls and were instructed to
maintain their standing balance via real-time visual biofeedback.
Three trials were given, and the mean tilt angle obtained for a 30-s
dynamic balance test was used for statistical analysis. Higher tilt
angles indicated poorer maintenance of dynamic balance.
2.5. Muscle strength measurements
The isokinetic muscle strengths of the quadriceps and hamstring
muscles were measured with a Con-Trex MJ dynamometer (Con-Trex,
Zurich, Switzerland). To stretch their muscles, participants underwent
a bicycling warm-up period of 10 min before testing. Participants were
placed in an upright position with the hip exed at 90 on the
dynamometer chair and with the chest, thigh, and ankle secured with
straps. The resistance pad was placed as distally as possible on the
tibia without decreasing dorsiexion at the ankle. The center of
motion of the lever arm was aligned as accurately as possible with the
epicondylar axis of the knee joint. The range of motion of the knee
joint was set from 0 to 100. The peak torque for the quadriceps and
hamstring was recorded at an angular velocity of 60/s. Measurements
for injured and uninjured sides were performed in random order.
2.6. Statistical analyses
Application of the KolmogorovSmirnov normality test (SPSS
software, SPSS Inc., Chicago, IL) conrmed the normal distribution of
all measurements. The paired t test was used to determine the
differences between the injured and uninjured sides for the test
parameters of knee laxity, proprioception, muscle strength, and tilt
angle in the dynamic balance test. The Pearson's coefcient of
correlation was used to determine the level of association between
the independent variables of knee laxity, proprioception, and muscle
strength and the dependent variable, the tilt angle in the dynamic
balance test. To eliminate the effect of sex difference, the 2 female
participants were excluded before the nal data analysis. Statistical

Fig. 3. Tracings of the sway paths in the single-limb stance balance test for a participant with (A) an uninjured leg and (B) an ACL-injured leg.

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H.-M. Lee et al. / The Knee 16 (2009) 387391

Table 3
Inuence of knee laxity, proprioception, and muscle strength on dynamic single-limb
standing balance for 10 male subjects with ACL injuries.
Tilt angle of dynamic balance
Injured side (n = 10)

Uninjured side (n = 10)

Pearson's coefcient P value Pearson's coefcient P value

Knee laxity
PRP proprioception
TTDPM proprioception
Quadriceps strength
Hamstrings strength
H/Q ratio
a

0.094
0.024
0.579
0.102
0.239
0.284

0.796
0.947
0.041a
0.778
0.506
0.427

0.109
0.129
0.583
0.014
0.367
0.659

0.764
0.723
0.047a
0.970
0.297
0.038a

Correlation is signicant at P = 0.05.

analyses were performed using the program package SPSS 11.5, and
the signicance level for all statistical analyses was P b 0.05.
3. Results
The Lysholm score for these patients before testing was 77.75 points (SD, 4.23;
range, 69 to 86). No signicant differences were observed between the toward exion
and toward extension positions in both the TTDPM and PRP proprioception tests; the
mean value of six measurements was used for further statistical analysis. However,
signicant differences between the injured and uninjured sides were observed for the
test parameters of knee laxity, TTDPM and PRP proprioception, the tilt angle in dynamic
balance, and muscle strength (Table 2). The hamstring/quadriceps (H/Q) ratio for the
injured side was not signicantly different from that of the uninjured side (P = 0.46).
The tracing of the sway path in the dynamic balance test of the uninjured leg revealed
that the test participants could adjust their posture to keep their center of gravity located
on the center of platform (Fig. 3A). By contrast, tracing of the sway path during testing of
the injured leg disclosed that the center of gravity consistently tilted in one direction and
could not be readjusted to the center of the platform (Fig. 3B). As independent variables,
knee laxity, PRP proprioception, and muscle strength did not inuence the dynamic
standing balance for the injured leg. However, a signicant positive correlation was
observed between TTDPM proprioception and dynamic stance balance with respect to
the injured limb (Table 3). Poorer TTDPM proprioception resulted in poorer dynamic
stance balance in the injured limb. For the uninjured limb, TTDPM proprioception and
the H/Q ratio were both found to inuence the dynamic standing balance (Table 3).
Poorer TTDPM proprioception and higher H/Q ratio resulted in poorer dynamic stance
balance in the uninjured limb.

4. Discussion
Findings of the present study showed that PRP proprioception did
not correlate with the dynamic standing balance of patients after ACL
injury. By contrast, TTDPM proprioception was found to be strongly
correlated with dynamic single-limb stance balance after ACL injury.
Proprioception is dened as the afferent information arising from the
internal peripheral area of the body and contributing to postural
control, joint stability, and specic conscious sensations [20]. A
reduction in knee proprioception has been reported to occur after
ACL injury [79], presumably because of disruption of mechanoreceptors within the ligament [35]. Because impairment of proprioception may lead to increased postural sway and, potentially, the loss
of balance [18], reports of compromised knee proprioception after ACL
injury have prompted researchers to study standing balance in
patients with such injuries [1315].
It has been reported that knee joint laxity does not correlate with
single-limb static standing balance in legs of patients with ACL injuries
[16]. In the present study, comparable results were obtained using the
single-limb dynamic standing balance test. Additionally, no correlation between knee joint laxity and single-limb dynamic standing
balance was observed for the uninjured knee. It should be noted that
Snyder-Mackler et al. [21] found no correlation between the
magnitude of passive knee laxity after ACL injury and functional
outcome. Knee joint laxity is therefore not likely to serve as a good
predictor for balance control and functional outcome.
Gibson et al. [22] examined the changes in the peak torque ratios of
the quadriceps and hamstring for persons with chronic ACL deciency.
Peak torque values were found to be signicantly decreased in the

ACL-decient as compared with the uninvolved limb; the peak torque

of the quadriceps decreased to a greater extent than that of the
hamstring in the ACL-decient limb. In addition, the concentric
hamstring/quadriceps peak torque ratio tends to be higher in the ACLdecient (0.71) than in the uninjured (0.65) limbs, but this difference
is not signicant [22]. Identical ndings were obtained in the present
study (Table 2). One possible explanation for the greater decrease in
quadriceps peak torque is an adaptive change in thigh muscle force,
brought about by the need to reduce the anterior tibial translation in
the ACL-decient knee.
The muscle strength (peak torque for quadriceps plus peak torque for
hamstring) in the ACL-injured leg does not correlate with balance in the
single-limb static stance [16]. In the present study, neither quadriceps
nor hamstring strength was found to correlate with single-limb dynamic
standing balance. However, muscle strength is only one measure of
muscle function. Other measures, such as muscle onset time, muscle
contraction time, muscle endurance, and muscle recruitment order, may
be of greater importance in maintaining postural balance than is muscle
strength [17]. Investigation of these measures is needed in order to
elucidate more fully the relationship between muscle function and
single-limb stance balance in ACL-decient patients.
It has been proposed that decreased postural control as dened by
higher amplitudes of center of pressure movements and decreased
proprioception as dened by higher TTDPM values are both features of
ACL injury [16,22]. In the present study, TTDPM proprioception, but not
RPP proprioception, was found to correlate positively with dynamic
single-limb stance balance. These observations may be explained by
the different requirements of the two forms of balance. In particular,
maintenance of dynamic stance balance requires a greater input of
information from quick-adapting mechanoreceptors and, therefore,
represents a greater challenge than does maintenance of static balance.
Certain limitations of the present study should be addressed. First,
only 12 participants (10 men and 2 women) were recruited, and only
the 10 men were included in the analysis. The small size of this group
reduces the statistical power of the ndings. The power is especially
low for the values of TTDPM and H/Q ratio. Although some
parameters are signicantly different between the injured and
uninjured sides in the paired-t test, the parameters with low power
have a high possibility for type II error and, an increase in sample size
is needed in future studies. Second, visual biofeedback was used to
control dynamic stance balance in this study. Visual input has the
capacity to improve dynamic stance balance and to compensate for
reductions in muscle strength or proprioception in patients with ACL
injuries. Studies comparable to the present study that examines ACL
patients under visually-blinded conditions are, therefore, planned.
5. Conclusions
TTDPM proprioception strongly correlated with dynamic single-limb
stance balance in patients with ACL injuries. By contrast, dynamic singlelimb stance balance in these individuals does not show signicant
correlation with knee laxity or the strength of the knee muscles.
Rehabilitation programs that improve TTDPM proprioceptive ability,
therefore, represent the most important approaches to improving
dynamic single-limb stance balance in patients with chronic ACL injuries.
6. Conict of interest statement
All authors disclose that no nancial or personal relationships with
other people or organizations exist that could inappropriately
inuence (bias) this work.
References
[1] Dye SF, Cannon Jr WD. Anatomy and biomechanics of the anterior cruciate
ligament. Clin Sports Med 1998;7:71525.

H.-M. Lee et al. / The Knee 16 (2009) 387391

[2] Reider B, Arcand MA, Diehl LH, Reider B, Arcand MA, Diehl LH. Proprioception of
the knee before and after anterior cruciate ligament reconstruction. Arthroscopy
2003;19:212.
[3] Kennedy JC, Weinberg HW, Wilson AS. The anatomy and function of the anterior
cruciate ligament. As determined by clinical and morphological studies. J Bone Jt
Surg Am 1974;56:22335.
[4] Schutte MJ, Dabezies EJ, Zimny ML, Happel LT. Neural anatomy of the human
anterior cruciate ligament. J Bone Jt Surg Am 1987;69:2437.
[5] Skinner HB, Barrack RL, Cook SD. Age related decline in proprioception. Clin Orthop
Rel Res 1984;184:20811.
[6] Lephart SM, Kocher MS, Fu FH, Borsa PA, Harner CD. Proprioception following
anterior cruciate ligament reconstruction. J Sports Rehab 1997;1:18896.
[7] Borsa PA, Lephart SM, Irrgang JJ, Safran MR, Fu FH. The effects of joint position and
direction of joint motion on proprioceptive sensibility in anterior cruciate
ligament-decient athletes. Am J Sports Med 1997;25:33640.
[8] Fremerey RW, Lobenhoffer P, Zeichen J, Skutek M, Bosch U, Tscherne H.
Proprioception after rehabilitation and reconstruction in knees with deciency
of the anterior cruciate ligament: a prospective, longitudinal study. J Bone Jt Surg
Br 2000;82:8016.
[9] Roberts D, Friden T, Stomberg A, Lindstrand A, Moritz U. Bilateral proprioceptive
defects in patients with a unilateral anterior cruciate ligament reconstruction: a
comparison between patients and healthy individuals. J Orthop Res 2000;8:56571.
[10] Shymway-Cook A, Woollacott M. Motor Control: Theory and Practical Applications.
Baltimore: Williams & Wilkins; 1995. p. 1201.
[11] Lane RE. Physiotherapy in the treatment of balance problems. Physiotherapy
1969;55:41520.
[12] Emery CA, Cassidy JD, Klassen TP, Rosychuk RJ, Rowe BH. Development of a clinical
static and dynamic standing balance measurement tool appropriate for use in
adolescents. Phy Ther 2005;85:50214.

391

[13] Gaufn H, Pettersson G, Tegner Y, Tropp H. Function testing in patients with old
rupture of the anterior cruciate ligament. Int J Sports Med 1990;11:737.
[14] Lysholm M, Ledin T, Odkvist LM, Good L. Postural controla comparison between
patients with chronic anterior cruciate ligament insufciency and healthy
individuals. Scand J Med Sci Sports 1998;8:4328.
[15] Zatterstrom R, Friden T, Lindstrand A, Moritz U. The effect of physiotherapy on
standing balance in chronic anterior cruciate ligament insufciency. Am J Sports
Med 1994;22:316.
[16] Ageberg E, Roberts D, Holmstrom E, Friden T. Balance in single-limb stance in
patients with anterior cruciate ligament injury: relation to knee laxity,
proprioception, muscle strength and subjective function. Am J Sports Med
2005;33:152735.
[17] Lee HM. Balance deciency in chronic ankle instability: evaluation by selfdesigning apparatus computerized balance-testing machine. J Med Sci 2000;21:
S5564.
[18] O'Connell M, George K, Stock D. Postural sway and balance testing: a comparison of
normal and anterior cruciate ligament decient knees. Gait Posture 1998;8:13642.
[19] Lee HM, Liau JJ, Cheng CK, Tan CM, Shih JT. Evaluation of shoulder proprioception
following muscle fatigue. Clin Biomech 2003;18:8437.
[20] Riemann BL, Bephant SM. The sensorimotor system, part I: the physiologic basis of
functional joint stability. J Athl Training 2002;37:719.
[21] Snyder-Mackler L, Fitzgerald GK, Bartolozzi III AR, Ciccotti MG. The relationship
between passive joint laxity and functional outcome after anterior cruciate
ligament injury. Am J Sports Med 1997;25:1915.
[22] Gibson ASC, Lambert MI, Durandt JJ, Scales N, Noakes TD. Quadriceps and
hamstrings peak torque ratio changes in persons with chronic anterior cruciate
ligament deciency. J Orthop Sports Phys Ther 2000;30:41827.