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Original articles
Is 12 months enough to reach function after athletes’ ACL reconstruction: a prospective longitudinal study
Ellen Cristina Rodrigues Felixa,
Corresponding author
ellenfelix@hotmail.com

Corresponding author.
, Angelica Castilho Alonsoa,b, Guilherme Carlos Brecha,b, Tiago Lazzaretti Fernandesa,c, Adriano Marques de Almeidaa,c, Natália Mariana Silva Lunaa, Jose Maria Soares-Juniord, Edmund Chada Baracatd, Arnaldo José Hernandeza,c, Júlia Maria D'Andrea Grevea
a Laboratory Study of Movement, Instituto de Ortopedia e Traumatologia do Hospital das Clínicas (IOT-HC) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
b Graduate Program in Aging Sciences from the Universidade São Judas Tadeu (USJT), Santos, SP, Brazil
c Sports Medicine Division, Institute of Orthopaedics and Traumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo; FIFA Medical Centre of Excellence, São Paulo, SP, Brazil
d Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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quadriceps and hamstrings muscles are also influenced by motor control&#44; the consequence is a decrease in quadriceps activation and greater flexor muscle activity of the knee&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a></p><p id="para0012" class="elsevierStylePara elsevierViewall">Ligament reconstruction restores anteroposterior stability but does not completely restore rotational stability&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Even after surgical intervention&#44; studies show that proprioceptive deficit remains&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0013" class="elsevierStylePara elsevierViewall">Some authors<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> reported functional deficits in athletes after returning to sports&#46; Only&#160;33&#37; of ACL reconstructed patients with hamstring graft and&#160;41&#37;&#160;with patellar graft have returned to their pre-injury sport condition&#44;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> and it increases the risk of reinjury&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0014" class="elsevierStylePara elsevierViewall">The most common measure of functional recovery during the rehabilitation program are clinical&#44; functional assessments evaluating muscle strength&#44; postural control&#44; and postural balance&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> The most commonly used clinical assessments are&#58;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> &#8220;Hop-Tests&#8221; &#8211; dynamic functional tests that perform tasks that measure performance&#59;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> Isokinetic dynamometry torque and muscle function &#40;strength&#41;&#59;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a> Posturography &#8210; force platforms for postural balance evaluation and postural control&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> Functional tests are easy to perform and useful&#44; &#8220;Hop-Tests&#8221;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> quantitative measures such as isokinetic dynamometry&#44; and static and dynamic posturography<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> are more accurate to measure the patient&#39;s functional improvement&#44; allowing a return to sports with more security&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0015" class="elsevierStylePara elsevierViewall">The controversy of the present study is that decreased muscle strength&#44; dynamic knee stability&#44; and functional performance after ACL after&#160;12&#160;months postoperatively could be associated with incomplete recovery of the knee stabilizing mechanism&#46;</p><p id="para0016" class="elsevierStylePara elsevierViewall">Therefore&#44; the aim of this study is to assess postural balance&#44; muscle strength&#44; and functional performance based on measures made upon a group of athletes with an ACL injury before and 12 months after surgery and matched control subjects&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Methods</span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Experimental design&#44; local and ethics</span><p id="para0017" class="elsevierStylePara elsevierViewall">A 12-month longitudinal observational prospective study was approved by the Local Ethics Committee of the Universidade de S&#227;o Paulo &#40;number&#160;652&#46;361&#41; and all of the subjects signed the informed consent&#46;</p><p id="para0018" class="elsevierStylePara elsevierViewall">The study was performed at the Motion Study Laboratory of the Institute of Orthopedics and Traumatology&#44; Hospital das Cl&#237;nicas&#44; University of S&#227;o Paulo School of Medicine&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Subjects</span><p id="para0019" class="elsevierStylePara elsevierViewall">The subjects were recruited into the study by a group of Sports Medicine from the hospital&#46; The sample was composed of&#160;74&#160;athletes from different sports activities who were included in this study&#46; The inclusion criteria for this study were&#58; &#40;1&#41;&#160;Recreational or professional athletes&#59; &#40;2&#41;&#160;Age between&#160;15&#160;and&#160;45&#160;years old&#59; &#40;3&#41;&#160;Sports practice of at least&#160;12&#160;months&#59; &#40;3&#41;&#160;Five or above in physical activity Tegner activity scale&#59; &#40;4&#41;&#160;No history of medical problems that limited activities within the&#160;6&#160;weeks before testing&#59; &#40;5&#41;&#160;Primary injury in ACL was accepted only for the ACL Injury Group&#46; The exclusion criteria were&#58; &#40;1&#41;&#160;History of previous knee injuries or leg surgeries&#59; &#40;2&#41;&#160;Associate lesions such as meniscus&#44; cartilage&#44; or other ligament injuries&#59; &#40;3&#41;&#160;Knee valgus and varus alignments&#59; &#40;4&#41;&#160;For the Control Group&#44; knee instabilities&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Allocation</span><p id="para0020" class="elsevierStylePara elsevierViewall">The athletes were in two groups&#58; the ACL injury Group &#40;27&#160;men and 7&#160;women&#41; and the Control Group &#40;athletes without the ACL injury&#44; 33&#160;men and 7&#160;women&#41;&#46; The ACL Group was a consecutive group of injured athletes that underwent ACL reconstruction surgery by two expert surgeons &#40;from the Sports Medicine Team&#41;&#44; and the time between the ACL injury to the first evaluation are more than three months apart in order to avoid the inflammatory period and a greater functional disability&#44; a restricted range of motion or swelling&#46; The Orthopedists from the team assessed the volunteers by magnetic resonance imaging&#44; clinical maneuvers&#44; and history of recurrent knee instability&#46; The Control Group was selected in agreement with the ACL Group&#39;s age&#44; gender&#44; and level of physical activities by the Tegner activity scale&#46; The subjects of the ACL group were assessed at baseline &#40;preoperative&#41; and 12 months after surgery&#46; The primary outcomes were the postural balance measures&#44; as assessed by the force plate&#46; Secondary outcomes included physical function tests and strength assessment&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">Follow-up was also performed by orthopedists at the hospital&#160;3&#160;weeks&#44; and 4&#44; 6&#44; 9 and 12 months following surgery&#46; Patients allocated to the ACL group were given detailed instructions about the rehabilitation program &#40;rehabilitation protocol&#41; and they could choose the rehabilitation center&#46; The rehabilitation progress was checked during the follow-up visits&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Postural balance</span><p id="para0022" class="elsevierStylePara elsevierViewall">The postural balance assessment &#40;posturography&#41; was performed on a portable force platform &#40;AccuSway Plus&#44; AMTI&#174;&#44; MA&#44; USA&#41;&#46; For data acquisition&#44; the force platform was connected to a signal-amplifying interface box &#40;PJB-101&#41; that was linked to a computer by means of an RS-232&#160;cable&#46; The data was gathered and stored using Balance Clinic&#174; software&#44; configured to a frequency of&#160;100&#160;Hz with a fourth-order Butterworth filter and a cutoff frequency of&#160;10&#160;Hz&#46; All subjects underwent the test with standardized positioning&#46; Two tests were performed &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#41;&#44; all with single-leg support&#58; knee flexion up to&#160;45&#176; &#40;as squat associated with straight trunk position&#41; &#40;Squat Test &#8211; <a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1B</a>&#41;&#44; and rotation of the trunk and hip &#40;simulating a kick with the outside edge of the foot&#41; &#40;Kick Test &#8211; <a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1C</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> The last test was performed through internal rotation of the trunk on the supporting limb&#44; with movement constantly repeated during the test period&#46; The movement speed was established according to the strategy adopted by each volunteer&#46; Each test was performed three times&#46; Knee flexion movement &#40;squat&#41; and kick simulation tests lasted&#160;10&#160;s&#46; There was an interval of&#160;30&#160;s between each test&#46; The arithmetic means of the results were calculated from the three tests conducted under each condition and were processed using the Balance Clinic&#174; software&#46; The parameters used to measure the subject&#39;s stability were the average of the Center of Pressure &#40;COP&#41; displacement in the anteroposterior direction &#40;cm&#41;&#59; the average of the COP displacement in the mediolateral direction &#40;cm&#41;&#59; the velocity of displacement oscillation &#40;cm&#47;sec&#41;&#59; and the area &#40;95&#37;&#160;of the area formed by the ellipse of the trajectory from the COP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><elsevierMultimedia ident="fig0001"></elsevierMultimedia></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0016">Functions mobility assessment</span><p id="para0023" class="elsevierStylePara elsevierViewall">The Single Leg Hop Test for a distance consists of a horizontal jump to the farthest possible distance using only one leg and keeping the hands behind the body&#46; Three jumps were performed with each leg&#44; with an interval of one minute between them&#44; and the arithmetic average of the distances of each jump was used&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> The single hop was considered successful if the landing was stable&#46; To be considered a valid trial&#44; the landing must be on one limb&#44; under complete control of the patient&#39;s stability&#46; If the patient landed with an early touchdown of the contralateral limb&#44; had a loss of balance&#44; or had additional hops after landing&#44; the hop would be repeated&#46; Patients were instructed to begin with the uninjured leg&#44; with their lead toe behind a marked starting line&#46; The hop distance was measured to the nearest centimeter from the starting line to the patient&#39;s heel with a standard tape measure&#46;</p></span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0017">Muscle strength assessments</span><p id="para0024" class="elsevierStylePara elsevierViewall">Isokinetic dynamometry was performed using the Biodex&#174; Multi-joint System&#160;3 &#40;Biodex Medical<span class="elsevierStyleSup">TM</span>&#44; Shirley&#44; NY&#44; USA&#46; The angular velocity used in the isokinetic test was&#160;60&#8304;&#47;s&#46; The isokinetic dynamometer was calibrated thirty minutes before starting the tests&#46; After a standardized warm-up&#44; the subjects were positioned for a concentric evaluation of extension and flexion movements of the knee joint&#46; They remained seated with the hips at&#160;90&#176; of flexion and were secured to the chair by belts&#46; The test was started with the uninjured limb&#46; The limb was evaluated by positioning the lateral condyle of the femur in alignment with the mechanical axis of the dynamometer&#46; All subjects performed four submaximal repetitions to become familiar with the equipment&#44; followed by a&#160;60-second rest interval&#44; then two series of four maximal repetitions of knee extension and flexion starting with the dominant limb&#44; with a&#160;60-second interval between the series&#46; The values from the second series were used for data analysis regarding the effects of motor learning on clinical isokinetic performance&#46; Constant standardized verbal encouragement was given during the tests in order to promote maximum effort during contractions&#46; The isokinetic variable used was maximum Peak Torque corrected for Body Weight &#40;PTQ&#47;BW&#41;&#46; Values were used to calculate Limb Index Symmetry &#40;LSI&#41;&#58; operated&#47;non-operated limb&#46;</p></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0018">Statistical analysis</span><p id="para0025" class="elsevierStylePara elsevierViewall">The sample size calculation was based on a pilot study with&#160;30&#160;subjects &#40;15&#160;with ACL Injury and 15&#160;without an ACL Injury&#41; and the variable used was the COP displacement direction average during the test after the surgery was considered&#46; The average COP displacement for the ACL Group was&#160;7&#46;63&#160;cm with a standard deviation of&#160;1&#46;84&#44; and for the Control Group&#44; it was&#160;6&#46;94&#160;cm with a standard deviation of&#160;1&#46;22&#46; To determine the sample size to compare the two means&#44; the power of the test was set at&#160;80&#37; with a&#160;5&#37; level of significance&#46; To meet these conditions&#44; at least&#160;40&#160;subjects were needed in each group&#44; considering&#160;a 10&#37;&#160;of loss of follow-up&#46;</p><p id="para0026" class="elsevierStylePara elsevierViewall">The comparison between the means of the quantitative variables related to the demographic data of the participants was carried out through the <span class="elsevierStyleItalic">U</span> Mann Whitney test&#46;</p><p id="para0027" class="elsevierStylePara elsevierViewall">For hop-test analysis&#44; isokinetic and dynamic evaluations of the force platform&#44; the Shapiro-Wilk normality test was performed&#46; <span class="elsevierStyleItalic">U</span>-Mann-Whitney test and Wilcoxon were used for non-parametric values&#44; all the tests were carried out at an alpha level of&#160;0&#46;05&#44; and the power of the study</p><p id="para0028" class="elsevierStylePara elsevierViewall">Demographic data was calculated using <span class="elsevierStyleItalic">U</span>-Mann-Whitney&#46; For hop-test analysis&#44; isokinetic and dynamic evaluations of the force platform&#44; Shapiro-Wilk normality test was performed&#46; <span class="elsevierStyleItalic">U</span>-Mann-Whitney test and Wilcoxon were used for non-parametric values&#44; all the tests were carried out at an alpha level of&#160;0&#46;05&#44; and the power of study was equal to&#160;80&#37; &#40;SPSS-9 for Windows&#41;&#46; Besides&#44; Cohen&#39;s D was used as a measure of effect size&#46;</p></span></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0019">Results</span><p id="para0029" class="elsevierStylePara elsevierViewall">The baseline analysis is presented in <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0030" class="elsevierStylePara elsevierViewall">There were no statistical differences between the groups regarding the baseline characteristics &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p><p id="para0031" class="elsevierStylePara elsevierViewall">The Tegner activity level scale scores were&#160;8&#160;&#40;&#177; 1&#46;3&#41; before and 7&#46;1&#160;&#40;&#177; 1&#46;82&#41; after ACL reconstruction in the ACL group and in the Control group were&#160;7&#46;6&#160;&#40;&#177; 1&#46;2&#41;&#46;</p><p id="para0032" class="elsevierStylePara elsevierViewall">Posturography assessment was shown in <a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><p id="para0033" class="elsevierStylePara elsevierViewall">In the Kick Test&#44; the area of COP oscillation decreased in the postoperative ACL Group only in the non-operated limb compared to the preoperative period&#44; and Control Group &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;0&#46;22&#41;&#46; In preoperative the ACL group the non-operated limb showed greater oscillation than the Control Group &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;0&#46;03&#41;&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">In the Squat Test&#44; the area of COP was smaller in the ACL Group when postoperative than in preoperative &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;0&#46;57&#41;&#46;</p><p id="para0035" class="elsevierStylePara elsevierViewall">Single-Leg Hop Test and Isokinetic evaluation are shown in <a class="elsevierStyleCrossRef" href="#tbl0003">Table&#160;3</a>&#46;</p><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><p id="para0036" class="elsevierStylePara elsevierViewall">Single-Leg Hop Test showed greater Limb Symmetry &#40;LSI&#41; in the ACL Group when postoperative compared to the preoperative period &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;0&#46;61&#41;&#46; The Control Group had a greater limb symmetry index than the preoperative ACL Group &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;0&#46;21&#41;&#46;</p><p id="para0037" class="elsevierStylePara elsevierViewall">Quadriceps showed greater limb symmetry in the ACL when postoperative compared to the preoperative period &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;1&#46;19&#41;&#46; The Control Group had greater LSI than the ACL Group during the preoperative &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;1&#46;87&#41; and postoperative period &#40;<span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#59; Effect Size&#160;&#61;&#160;0&#46;59&#41;&#46; There was no difference in hamstring strength &#40;limb symmetry index&#41;&#46;</p></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0020">Discussion</span><p id="para0038" class="elsevierStylePara elsevierViewall">The main finding of this study is that&#44; although postural control and muscle strength can suffer adaptive changes after reconstruction in the ACL&#44; nevertheless&#44; there are deficits compared to the control group&#46; Single-Leg Hop Test and the quadriceps strength symmetry limb index increased in the postoperative period in the ACL group compared to preoperative&#44; but not at the same level as the Control Group&#46; Nevertheless&#44; the COP oscillation area decreased in the postoperative period during the Squat Test on operated limbs and during the Kick Test on non-operated limbs&#44; Higher scores in the Tegner Scale were found in the preoperative period showing that preinjury levels were not reached in&#160;12&#160;months following the reconstruction&#46; Volpi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> Hohmann et al&#46;&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Teitsma et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> reported how difficult it is to reach total recovery after the ACL reconstruction&#46; The number of athletes returning to the pre-injury level is growing due to advances in knowledge of ACL injury&#44; reconstruction&#44; and rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a> Demographic&#44; functional&#44; psychological&#44; and socioeconomic factors may influence the successful safe return to sports&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Some authors<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> have reported that male gender athletes&#44; age&#160;&#8804;&#160;24&#160;years old&#44; elite athletes&#44; successfully reconstructed&#44; rehabilitated&#44; and motivated athletes return to sports at the same preinjury level&#46; In the present study&#44; even the athletes that did not return to the supposed same preinjury level showed good recovery in the postoperative period&#46; Higher Tegner scale levels are reached by high-intensity sports that require higher knee stability such as soccer and rugby&#46;</p><p id="para0039" class="elsevierStylePara elsevierViewall">The functions mobility assessment shown in the Single Hop-test &#40;symmetry index&#41;&#44; which compares the distances skipped by the two limbs&#44; is an important variable that improves the evaluation of treatment&#44; since it serves as a normalizer of the anthropometric differences&#46; In addition&#44; being a useful measure to compare the two members together&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> In the present study&#44; there was an improvement &#40;increase&#41; in the symmetry index in the postoperative period&#44; when compared to the preoperative period&#46; The Control Group showed&#160;100&#37; &#40;index&#160;&#61;&#160;1&#41; symmetry&#44; a result that was not fully restored by the postoperative ACL Group&#44; which reached&#160;96&#37; &#40;index&#160;&#61;&#160;0&#46;96&#41;&#44; but was very close&#46; The preoperative ACL index of symmetry was&#160;88&#37;&#46; The symmetry index&#160;&#8805; 90&#37; is part of the criteria for returning to the sports but must be evaluated along with the following parameters&#58; muscular strength&#44; postoperative time&#44; and neuromuscular control&#46;</p><p id="para0040" class="elsevierStylePara elsevierViewall">Logerstedt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a> reported that the symmetry between the limbs in the Single-Leg Hop Test at the end of six months is a predictive factor of good function&#46; Gustavsson et al&#46; &#40;2006&#41;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> showed&#160;6&#37; asymmetry in a group of healthy individuals&#44; 21&#37;&#160;in the non-operated ACL group&#44; and 20&#37;&#160;in the six-month reconstruction group&#46; In the present study&#44; with a&#160;12-month postoperative period&#44; the improvement of the symmetry is observed&#44; at levels that allow the return to sportive activity with safety&#46; This data strongly suggests that a safe return to sports is a multifactorial decision and the time after the surgery is an important aspect but cannot be the only one to be considered&#46;</p><p id="para0041" class="elsevierStylePara elsevierViewall">Another interesting fact was that the non-operated limb showed a better evolution in the postoperative period compared with the operated limb in the Kick Test&#46; The Area of COP oscillation in the preoperative period was greater than in the postoperative period&#44; and when compared to the Control Group&#46; This better response of the non-operated limb can be explained by the integrity of the ACL&#44; because with mechanoreceptors functioning normally&#44; the limb is able to respond better to sensory motor training&#46; In the Squat Test&#44; the operated limbs of the ACL Group decreased their area of COP oscillation in the postoperative period&#46; This lower area of COP displacement may be related to the improvement of the afferents and sensorial responses after the reconstruction&#46; Bryant et al&#46; &#40;2009&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a> reported changes in muscle activation after reconstruction&#46; Quadriceps activation decreased while the hamstring increased to avoid the anteriorization of the tibia during the movements&#46; It could be expected&#44; also in the Squat Test&#44; some differences in COP oscillation compared to the ACL and Control Group&#44; probably the closed chain movement with higher muscle action of the knee was enough&#44; there wasn&#39;t an increased oscillation area&#44; compared to normal individuals&#46;</p><p id="para0042" class="elsevierStylePara elsevierViewall">In two systematic reviews&#44; Negahban et al&#46; &#40;2014&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> with non-operated injuries&#44; and Howell et al&#46; &#40;2011&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> after reconstruction&#44; the results showed that the injured&#47;operated limbs presented greater displacement of the COP area&#44; besides the higher oscillation velocity when compared with contralateral limb and the Control group&#46; Negahban et al&#46; &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> also referred to bilateral but always a greater deficiency in the injured limbs&#44; and Howell et al&#46; &#40;2011&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> observed the existence of postural control deficiency two years after reconstruction&#46; The results of the present study are in agreement with those found in the two reviews&#44; although differences in the types of evaluation should be considered&#46; Postural balance is developed and improves physical fitness throughout life that involves several body systems and&#44; therefore&#44; it is hard to evaluate during functional tasks&#46; Postural control is not always compromised in the ACL injury because there is a loss of the ruptured ligament proprioception&#44; but other structures and systems come into action to overcome this failure&#46; This factor may be the basis of the controversial results seen in the assessment of postural balance control in ACL injury&#58; differences between the evaluated patients&#44; the tests used&#44; and the compensatory proprioceptive strategies used&#46; There is a controversy in literature on whether decreasing oscillation of COP is necessary to improve function after ACL reconstruction&#44; maybe the difference in literature is due to adaptive changes to improve function&#46;</p><p id="para0043" class="elsevierStylePara elsevierViewall">Peak torque is the most common variable for measuring muscle strength and it is evaluated by symmetry limb index&#44; which is a criterion to evaluate rehabilitation and return to sports<a class="elsevierStyleCrossRef" href="#bib0027"><span class="elsevierStyleSup">27</span></a>&#46; Lepley et al&#46; &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0028"><span class="elsevierStyleSup">28</span></a> concluded that muscle strength has more importance on knee function than muscle activation&#46; After&#160;12&#160;months of patellar tendon reconstruction&#44; there was no difference in the hamstring symmetry limb index&#44; in this study&#46; But the quadriceps limb symmetry improved in the postoperative period&#44; but still showed symmetry deficit compared to the Control Group &#40;which means incomplete recovery occurred&#41;&#46; This result is not expected&#44; taking into account that the risk of injury is probably due to the effect of muscle training during and after rehabilitation&#46; Some authors&#44; such as Abrams et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> Pamukoff et al&#46;<a class="elsevierStyleCrossRef" href="#bib0029"><span class="elsevierStyleSup">29</span></a> found a peak torque deficit in the extensor muscles and in the flexors postoperatively&#44; the deficit was higher in the quadriceps&#46;</p><p id="para0044" class="elsevierStylePara elsevierViewall">While the extensor muscles &#40;quadriceps&#41; are the most affected in knee injuries&#44; they are also the most important for the postoperative function acquisition and stability in ACL reconstructions<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">30</span></a>&#46; Rehabilitation may influence muscle recovery&#44; mainly because volunteers from the studies are treated with different rehabilitation protocols&#46; Hamstring symmetry did not show improvement&#44; probably because it lost less strength than the quadriceps did&#46; These results differ from the findings of Czaplick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0031"><span class="elsevierStyleSup">31</span></a> and Konrath et al&#46;<a class="elsevierStyleCrossRef" href="#bib0032"><span class="elsevierStyleSup">32</span></a> who observed the existence of peak torque deficit in the flexor muscles in flexor tendon reconstructions&#46; These authors evaluated patients&#160;12&#160;to&#160;24&#160;months after surgery&#44; when patients should have returned to sports practice&#46; Many authors use the non-operated limb as a parameter of normality&#44; mainly because many patients are only evaluated during the postoperative period&#44; thus using the limb without injury and&#47;or Control group comparisons&#46; Westin-Barber and Noyes&#44;<a class="elsevierStyleCrossRef" href="#bib0033"><span class="elsevierStyleSup">33</span></a> under a systematic review&#44; found the index of symmetry among the members as the criterion most cited in the articles&#44; so the authors used the variable in the study&#46; However&#44; the limb without injury can also present a deficit&#44;<a class="elsevierStyleCrossRef" href="#bib0034"><span class="elsevierStyleSup">34</span></a> as seen in the current study&#44; impairing the evaluation of the patient&#46;</p><p id="para0045" class="elsevierStylePara elsevierViewall">There are some limitations in this study&#44; there was no standardization of rehabilitation in a single center&#44; although they have received detailed instructions about the rehabilitation protocol&#44; and the rehabilitation progress was checked during the follow-up visits&#59; even force platform is considered the gold standard method for balance control&#44; it was difficult to compare this study to others with the same methodology&#44; using the dynamic performance &#40;Squat and Kick Test&#41; in the force platform as used in this present study&#44; even force platform is considered the gold standard method for balance control&#59; and also muscle strength of other parts of the body&#44; knee valgus and kinematics parameters of tests were not evaluated&#46; The authors suggest that future studies should also perform dynamic evaluations&#44; as well as using functional tests&#44; associated with kinematics measures&#44; and thus it would improve the quality of information around parameters related to the COP displacement and functional evaluation in the ACL injury&#46;</p><p id="para0046" class="elsevierStylePara elsevierViewall">One important clinical implication of this study was that even after athletes return to sports they present physical deficits&#44; athletes haven&#180;t returned to the same physical activity level as before the ACL injury&#46;</p></span><span id="sec0012" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0021">Conclusion</span><p id="para0047" class="elsevierStylePara elsevierViewall">The result indicates incomplete adaptive changes in postural control&#44; muscle strength and functional recovery after injury&#44; reconstruction and the return to sport&#46;</p><span id="sec0013" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0022">Author&#39;s contributions</span><p id="para0048" class="elsevierStylePara elsevierViewall">Ellen Cristina Rodrigues Felix&#58; Investigation and writing-original draft and supporting&#46;</p><p id="para0049" class="elsevierStylePara elsevierViewall">Angelica Castilho Alonso&#58; Supporting investigation and writing-review &#38; editing&#46;</p><p id="para0050" class="elsevierStylePara elsevierViewall">Guilherme Carlos Brech&#58; Supporting investigation and writing-review &#38; editing&#46;</p><p id="para0051" class="elsevierStylePara elsevierViewall">Tiago Lazzaretti Fernandes&#58; Formal analysis and writing-review &#38; editing&#46;</p><p id="para0052" class="elsevierStylePara elsevierViewall">Adriano Marques de Almeida&#58; Formal analysis and writing-review &#38; editing&#46;</p><p id="para0053" class="elsevierStylePara elsevierViewall">Nat&#225;lia Mariana Silva Luna&#58; Investigation and writing-original draft and supporting&#46;</p><p id="para0054" class="elsevierStylePara elsevierViewall">Jose Maria Soares-Junior&#58; Supporting investigation and writing-review &#38; editing&#46;</p><p id="para0055" class="elsevierStylePara elsevierViewall">Edmund Chada Baracat&#58; Supporting investigation and writing-review &#38; editing&#46;</p><p id="para0056" class="elsevierStylePara elsevierViewall">Arnaldo Jos&#233; Hernandez&#58; Supporting investigation and writing-review &#38; editing&#46;</p><p id="para0057" class="elsevierStylePara elsevierViewall">J&#250;lia Maria D&#39;Andrea Greve&#58; Supervisor and writing-review &#38; editing&#46;</p></span></span></span>"
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      "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><p id="spara009" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">&#8226;</span><p id="para0001" class="elsevierStylePara elsevierViewall">Anterior cruciate ligament injury is disabling in several sports&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">&#8226;</span><p id="para0002" class="elsevierStylePara elsevierViewall">nterior cruciate ligament injury causes knee instability and functional deficit&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0003"><span class="elsevierStyleLabel">&#8226;</span><p id="para0003" class="elsevierStylePara elsevierViewall">Usually&#44; surgical treatments produce best functional outcomes&#46;</p></li></ul></p></span>"
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        "resumen" => "<span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Context</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">Anterior Cruciate Ligament &#40;ACL&#41; injury is disabling in several sports because it causes knee instability and functional deficit&#46; Usually&#44; surgical treatments produce the best functional outcomes&#44; however&#44; sometimes they are not always able to fully restore stability and function&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Objective</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">The objective of this study was to evaluate postural balance&#44; muscle strength&#44; and functional performance of young athletes with an ACL injury before and after ACL reconstruction&#46;</p></span> <span id="abss0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Design</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">This was a longitudinal observational prospective study&#46;</p></span> <span id="abss0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0006">Method</span><p id="spara013" class="elsevierStyleSimplePara elsevierViewall">74&#160;athletes&#44; 60&#160;men&#44; and 14&#160;women&#44; aged between&#160;16&#160;and&#160;45&#44; divided into two groups&#58; the Group-Lesion of ACL with&#160;34&#160;athletes &#40;24&#46;1&#160;years&#41; and the Group-Control with&#160;40&#160;athletes without ACL lesion &#40;27&#46;7&#160;years old&#41;&#46; All volunteers performed posturography&#44; isokinetic dynamometry&#44; and the Hop-Test&#46; The ACL-Group was evaluated before and 12&#160;months after the reconstruction and the control group was evaluated once&#46;</p></span> <span id="abss0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Results</span><p id="spara014" class="elsevierStyleSimplePara elsevierViewall">The Postoperative ACL Group presented greater limb symmetry&#44; 0&#46;96&#160;&#40;&#177; 0&#46;12&#41;&#44; than the preoperative ACL Group&#44; 0&#46;87&#160;&#40;&#177; 0&#46;17&#41;&#44; <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#46;01 in the Hop-Test&#46; In the posturography&#44; the displacement area was smaller in the postoperative ACL Group&#44; 19&#46;85&#160;&#40;&#177; 5&#46;74&#41;&#44; compared to the preoperative ACL Group&#44; 24&#46;20&#160;&#40;&#177; 8&#46;97&#41;&#44; <span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#46; In isokinetic dynamometry the torque peak was greater in the postoperative ACL Group&#44; 0&#46;91&#160;&#40;&#177; 0&#46;14&#41;&#44; than in the preoperative ACL Group&#44; 0&#46;74&#160;&#40;&#177; 0&#46;15&#41;&#44; <span class="elsevierStyleItalic">p&#160;&#60;</span>&#160;0&#46;01&#46;</p></span> <span id="abss0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Conclusion</span><p id="spara015" class="elsevierStyleSimplePara elsevierViewall">The functional outcomes increased in ACL reconstruction athletes after&#160;12 months&#44; but not at the same level as in the Control Group&#46; The result indicates an incomplete functional recovery&#44; adaptive changes in postural control after injury&#44; reconstruction&#44; and return to sport&#46;</p></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0041"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0042"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">F &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0043"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0044"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">F &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0045"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0046"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0047"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0053"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">79&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">82&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0059"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">20&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">17&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0065"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0071"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Professional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">35&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">27&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0077"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Amateur&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">64&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">72&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0081"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3252506.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of patients of both groups&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0002"
        "etiqueta" => "Table&#160;2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0002"
            "detalle" => "Table&#63;"
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spara006" class="elsevierStyleSimplePara elsevierViewall">ACLG&#44; Anterior Cruciate Ligament Group&#59; CG&#44; Control Group&#59; &#40;d&#41; Cohen&#39;s D&#58; measure of effect size&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0083"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0084"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="4" align="left" valign="top" scope="col">ACLG &#40;<span class="elsevierStyleItalic">n&#160;&#61;</span>&#160;34&#41;</th><a name="en0085"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">CG &#40;<span class="elsevierStyleItalic">n&#160;&#61;</span>&#160;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0086"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0087"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><a name="en0088"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0089"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top" scope="col">Preoperative</th><a name="en0090"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="top" scope="col">Postoperative</th><a name="en0091"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0092"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0093"></a><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Effect size &#40;d&#41;</th></tr><tr title="table-row"><a name="en0094"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0095"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">Operated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0096"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">Non operated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0097"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">Operated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0098"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">Non operated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0099"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0100"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><a name="en0102"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0103"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0104"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0105"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0106"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0107"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0108"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0109"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0110"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Kick Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0111"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">26&#46;29 &#40;10&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0112"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">31&#46;77 &#40;11&#46;88&#41;<a class="elsevierStyleCrossRef" href="#tb2fn3"><span class="elsevierStyleSup">c</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tb2fn4"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0113"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">24&#46;38 &#40;8&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0114"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">24&#46;91 &#40;6&#46;39&#41;<a class="elsevierStyleCrossRef" href="#tb2fn4"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0115"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">23&#46;36 &#40;7&#46;22&#41;<a class="elsevierStyleCrossRef" href="#tb2fn3"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0116"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0117"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;03&#8210;0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0118"></a><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="top">Squat Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0119"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">24&#46;20 &#40;8&#46;97&#41;<a class="elsevierStyleCrossRef" href="#tb2fn1"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0120"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">24&#46;05 &#40;10&#46;42&#41;&nbsp;\t\t\t\t\t\t\n
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                        0 => array:2 [
                          "etal" => false
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Article information
ISSN: 18075932
Original language: English
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