[ literature review ]

NICKY VAN MELICK, PT, PhD1  •  WALTER VAN DER WEEGEN, PhD1  •  NICK VAN DER HORST, PT, PhD2

Quadriceps and Hamstrings Strength

Reference Values for Athletes With and
Without Anterior Cruciate Ligament
Reconstruction Who Play Popular Pivoting
Sports, Including Soccer, Basketball,
and Handball: A Scoping Review

Q
uadriceps and hamstrings strength tests are important when The limb symmetry index (LSI)—a
evaluating rehabilitation progression and making return- comparison between the operated and
to-sport (RTS) decisions after anterior cruciate ligament nonoperated limbs—is often used to
guide RTS decisions. However, clini-
reconstruction (ACLR).7,43,53 Athletes who play pivoting sports
cians and researchers have long raised
and who pass strength tests as part of an RTS testing protocol are concerns about using the nonoperated
at lower risk for a second anterior cruciate ligament (ACL) injury, limb as a reference, as the nonoperated
underscoring the importance of these tests.18,19,30 limb also detrains and loses strength after
injury and surgery.57 As a result, the LSI
U OBJECTIVE: To synthesize and present reference U RESULTS: Of the 42 included studies, 26 may overestimate operated-knee function
values for quadriceps and hamstrings strength tests reported reference values from healthy soccer and may not be sensitive enough to alert
in healthy athletes who play pivoting sports and in players, 4 from healthy basketball players, 4 from
athletes with anterior cruciate ligament reconstruc- clinicians and athletes to a high risk of
healthy handball players, and 11 from other healthy
tion (ACLR) who play pivoting sports. pivoting-sport athletes. The limb symmetry index
second ACL injury.57
U DESIGN: Scoping review. dominant/nondominant limb (LSI-D/ND) ranged The use of both LSI and preinjury
U LITERATURE SEARCH: We searched PubMed, from 98% to 114% for healthy athletes. Six studies strength values to guide rehabilitation
the Cochrane Library, MEDLINE, Embase, and Web reported reference values in pivoting-sport athletes progression could be a solution, but pre-
of Science up to January 26, 2021. with ACLR at a specific time point during rehabili- injury data are often unavailable in every-
U STUDY SELECTION CRITERIA: We included tation. After 7 months, strength values for athletes day practice. Strength test reference values
reference values in 2 different categories: (1) quad- with ACLR were comparable to those of healthy derived from healthy athletes who play
riceps and hamstrings strength test outcomes in pivoting-sport athletes.
pivoting sports could solve this problem,
healthy pivoting-sport athletes, and (2) quadriceps U CONCLUSION: This scoping review sum- but a comprehensive overview of refer-
and hamstrings strength test outcomes in pivoting- marizes quadriceps and hamstrings strength
sport athletes with ACLR at a specific time point ence values for different sports is currently
reference values for athletes who play the most
during rehabilitation. lacking.
common pivoting sports, including soccer,
U DATA SYNTHESIS: We performed a qualita- basketball, and handball. J Orthop Sports Phys
We aimed to synthesize and pre­sent
tive synthesis for reference values from isokinetic Ther 2022;52(3):142-155. Epub 31 Dec 2021. reference values for quadriceps and ham-
(at 60°/s, 180°/s, and 300°/s) and isometric strings strength tests in athletes with and
doi:10.2519/jospt.2022.10693
quadriceps and hamstrings strength tests. We
U KEY WORDS: anterior cruciate ligament recon-
without ACLR who play pivoting sports.
summarized the data for type of sport, sex, sport
participation level, and age group. struction, muscle strength, reference values The goal of our scoping review was to
present information to help clinicians

1
Sports and Orthopaedics Research Center, Anna Hospital, Geldrop, the Netherlands. 2PSV Eindhoven, Eindhoven, the Netherlands. The authors certify that they have no affiliations
with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr
Nicky van Melick, Sports and Orthopaedics Research Center, Anna Hospital, Bogardeind 2, 5664 EH Geldrop, the Netherlands. E-mail: [email protected] t Copyright ©2022
JOSPT®, Inc

142 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

understand what “normal” quadriceps for eligibility. For all potentially eligible torque; peak torque normalized to body
and hamstrings strength is for the ath- studies, a full-text version was reviewed weight (BW); total work (only reported
letes they work with: what to expect from by 2 authors (W.v.d.W. and N.v.d.H.). for an endurance test with at least 10
healthy players without ACLR, and what Any disagreements in both steps were repetitions and when a test range was
to expect during rehabilitation and RTS resolved by consensus. After this, both described); LSI, calculated as [(operated
progressions after ACLR. We present quadriceps and hamstrings strength leg/nonoperated leg) × 100%] for ath-
reference values for different pivoting Rayyan40 files were combined, and dupli- letes with ACLR LSI-D/ND calculated
sports, sexes, sport participation levels cates were removed. as [(dominant leg)/(nondominant leg) ×
(elite and nonelite), and age groups. 100%] for healthy athletes54; concentric
Data Synthesis hamstrings-to-quadriceps ratio; dynamic
METHODS One author (N.v.M.) extracted all rele- control ratio (eccentric hamstrings-to-
vant study characteristics and reference concentric quadriceps); and maximum

T
his scoping review was conduct- value data. Study characteristics includ- voluntary isometric contraction (MVIC).
ed and reported according to the ed author and year of publication, pop- Limb symmetry indexes and ratios were
Preferred Reporting Items for ulation characteristics, test details, and extracted or calculated from the indi-
Systematic reviews and Meta-Anal- test outcome variables. Reference val- vidual studies. When LSIs based on both
yses extension for Scoping Reviews ues were categorized as pivoting-sport peak torque and peak torque normalized
(PRISMA-ScR).49 athlete with or without ACLR, type of to BW were available, only the LSI based
sport, sex, sport level (elite or nonelite), on peak torque normalized to BW was
Eligibility Criteria and age group (adolescent [16-19 years reported.
Inclusion and exclusion criteria were spec- of age] or young adult [20-35 years of When 3 or more studies reported on
ified for 2 different categories of reference age]).60 the same sport, we created a reference
values: (1) quadriceps and hamstrings Test outcome variables were reported value table for the sport. We grouped
strength test outcomes in pivoting-sport as the following reference values: peak data from all other sports (reported in
athletes with ACLR at a specific time point
during rehabilitation, from 3 months to
Inclusion and Exclusion Criteria for
RTS, and (2) quadriceps and hamstrings
TABLE 1 Reference Values Derived From Healthy and
strength test outcomes in healthy pivot-
ACL-Reconstructed Pivoting-Sport Athletes
ing-sport athletes, which can be used as
RTS criteria (TABLE 1).
Inclusion Exclusion
Population • Adolescents (mean age, 16-19 y) or young adults (mean • Healthy athletes: history of ACL injury
Search Strategy age, 20-35 y) or surgery in the past, or other lower
On January 26, 2021, a systematic lit- • Athletes performing pivoting sports (clear sports extremity or lower back injury when
erature search was performed by an aca- description, Tegner score ≥6, or level 1 or 2 sportsa) tested
demic librarian. PubMed, the Cochrane • Athletes with ACLR • Athletes with ACLR
- Potential concomitant MCL or LCL injuries - ACL revision surgery or contralateral
Library, MEDLINE, Embase, and Web
- Potential concomitant meniscal or cartilage injuries ACL injury in the past
of Science were searched from database • Male or female athletes - Concomitant PCL injuries
inception to identify relevant articles, • Elite or recreational athletes
using key words specified for the data- Outcome • Strength tests for quadriceps or hamstrings with an • No separate results for male and female
base (supplemental file 1). In addition, a isokinetic dynamometer (isometric or concentric/ athletes
eccentric at 60°/s-180°/s-300°/s50) or a handheld • No separate results for elite or recre-
hand search of the reference lists of me-
dynamometer ational athletes
ta-analyses and systematic reviews was • Absolute values or limb symmetry indexes reported as • Athletes with ACLR: tests performed
conducted to identify additional studies an outcome more than 1 y after ACLR
not found in the primary search. • Athletes with ACLR: tests performed at a specific time
All database records were exported to point during rehabilitation, from 3 mo until the moment
of return to sport
the Rayyan application40 in separate files
Publication • All original research types • Meta-analyses, systematic or narrative
for quadriceps and hamstrings strength. type • Language: English, Dutch, or German reviews, conference abstracts, posters
Duplicates were removed from each file. Abbreviations: ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction;
LCL, lateral collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.
Study Selection Level 1 sports are sports with frequent pivoting movements (eg, soccer, handball, basketball); level
a

2 sports are sports with lateral movements and less pivoting than level 1 sports (eg, racket sports,
Two authors (N.v.M. and W.v.d.W.) inde- alpine skiing).22
pendently screened titles and abstracts

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | 143

 [ literature review ]
2 or fewer studies) in 1 extra reference RESULTS measurements using an isokinetic dy-
value table. namometer, with a Biodex (Biodex
All outcome variables reported in 2 or Study Selection Medical Systems, Shirley, NY) or Cybex

A
more studies were presented as a weight- fter removing duplicates, the (Life Fitness, Rosemont, IL) being used
ed mean with a weighted standard devia- systematic literature search yielded most often (55% and 33%, respectively).
tion. The weighted mean was calculated 712 articles for quadriceps strength Thirty-nine studies measured isokinetic
as the sum of (study mean × study sample and 246 articles for hamstrings strength. strength only, 2 measured isometric
size), divided by the sum of all study sam- After screening titles, abstracts, and full strength only, and 1 measured isokinetic
ple sizes. texts for eligibility, 926 articles were ex- and isometric strength.
The weighted standard deviation was cluded, leaving 32 articles for quadri-
calculated as the sum of (study variance × ceps and hamstrings strength combined. Isokinetic Strength Testing Protocols
study sample size), divided by the sum of Hand searching reference lists of meta- Two studies measured concentric
all study sample sizes. Study variance was analyses and systematic reviews provided quadriceps strength only, 28 stud-
calculated as study mean minus weighted 10 additional articles; 42 articles were in- ies measured concentric quadriceps
mean. cluded for data synthesis (FIGURE). and hamstrings strength, 6 studies
Outcome variables reported in a sin- measured concentric quadriceps and
gle study were displayed as mean ± SD. Overview of Strength Testing Protocols concentric plus eccentric hamstrings
Standard deviation was not available if Data on study characteristics are de- strength, and 4 studies measured con-
we calculated the LSI or ratio from data scribed in supplemental file 2. All in- centric plus eccentric quadriceps and
extracted from a specific study. cluded studies performed strength hamstrings strength.

Quadriceps strength Hamstrings strength

Identification

Records identified through Records identified through

database searching, n = 889 database searching, n = 320

Records after duplicates Records after duplicates

removed, n = 712 removed, n = 246
Screening

Records excluded, n = 464 Records screened, n = 712 Records screened, n = 246 Records excluded, n = 152
• Wrong population, n = 320 • Wrong population, n = 88
• Wrong outcome, n = 88 • Wrong outcome, n = 38
• Wrong publication type, n = 56 • Wrong publication type, n = 26
Full-text articles assessed for Full-text articles assessed for
eligibility, n = 248 eligibility, n = 94
Full-text articles excluded, n = 216 Full-text articles excluded, n = 94
• Wrong population, n = 183 • Wrong population, n = 53
• Wrong outcome, n = 33 • Wrong outcome, n = 13
• Duplicate with quadriceps
Eligibility

Studies included from Studies included from strength, n = 28

databases, n = 32 databases, n = 0

Studies included from

databases, n = 32
Additional records identified
through reference list
searching, n = 10
Included

Studies included in qualitative

synthesis, n = 42

FIGURE. PRISMA flow chart of the study inclusion process.

144 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

 Thirty-six studies performed con- 90° to 0° of flexion were mentioned in studies. 2,6,9-12,14,15,17,20,21,24,29,33,34,39,41,44-46,48,
centric strength measurements at 60°/s, 15% and 33%, respectively. Rest between 51,55,56,59,62
There were data from 1987 soc-
usually with 3 or 5 repetitions (39% and sets and whether gravity correction was cer players (84% male) who were 24.0 ±
42%, respectively). Seventeen studies re- performed were usually not described. 2.1 years of age (TABLE 2).
ported strength measurements at 180°/s Basketball  Strength results from healthy
and/or 300°/s, typically with 3 or 5 repe- Isometric Strength Testing Protocols basketball players were reported in 4
titions (29% and 35%, respectively). One Isometric strength measurements were studies.16,29,33,47 There were data from 99
study that reported total work as an out- all performed at different knee angles healthy basketball players (74% male) who
come parameter performed more than (45°, 70°, or 90° of flexion) and with dif- were 22.5 ± 0.99 years of age (TABLE 3).
10 repetitions at these higher speeds.63 ferent durations (2, 3, or 4 seconds). Handball  Strength results from healthy
Eccentric strength was typically mea- handball players were reported in 4
sured over 5 repetitions (70%). Range Quadriceps and Hamstrings Strength studies.2,16,31,44 There were data from 310
of motion was not specified in 33% of all Test Results handball players (5% male) who were
isokinetic studies. In those that reported Soccer  Strength results from healthy 21.3 ± 1.3 years of age (TABLE 4).
range of motion, 100° to 0° of flexion and soccer players were reported in 26 Other Pivoting Sports  All other pivoting

Quadriceps and Hamstrings Strength Reference Values From
TABLE 2
Healthy Soccer Players2,6,9-12,14,15,17,20,21,24,29,33,34,39,41,44-46,48,51,55,56,59,62

Isokinetica Isometrica
Sex/Sport Level Populationa 60°/s 180°/s 300°/s 90°
Male
Elite n = 58 adolescents Quadriceps Quadriceps Quadriceps Quadriceps
Age, 17.1 ± 0.8 y15,21,41 Peak torque, 182 ± 28 Nm Peak torque, 145 ± 13 Nm Peak torque, 122 ± 14 Nm MVIC, 409 ± 78 N
D/ND LSIb = 102% ± 15% D/ND LSIb = 99%d D/ND LSIb = 99%d Hamstrings
Hamstrings Eccentric peak torque, 244 ± Eccentric peak torque, 249 ± MVIC, 173 ± 38 N
Peak torque, 97 ± 18 Nm 42 Nm 41 Nm
D/ND LSIb = 108% ± 18% Hamstrings Hamstrings
Eccentric peak torque, 151 ± Peak torque, 87 ± 15 Nm Peak torque, 72 ± 9 Nm
29 Nm D/ND LSIb = 98%d D/ND LSIb = 99%d
Ratio Eccentric peak torque, 138 ± Eccentric peak torque, 141 ±
DCRc = 84%d 21 Nm 23 Nm
Ratios Ratios
HQRe = 61% ± 9% HQRe = 61% ± 7%
DCRc = 96% ± 20% DCRc = 117% ± 23%
n = 1499 young Quadriceps Quadriceps Quadriceps
adults Peak torque, 239 ± 16 Nm Peak torque, 168 ± 14 Nm Peak torque, 134 ± 6 Nm
Age, 24.9 ± 1.2 y2,6,9, Peak torque per BW, 3.17 ± –0.10 Peak torque per BW, 2.56 ± –0.10 Peak torque per BW, 1.87 ± –0.01
11,12,14,17,20,21,24,33,34,45,
Nm/kg Nm/kg Nm/kg
46,51,55,59,62
D/ND LSIb = 99% ± 2% D/ND LSIb = 103% ± 0% D/ND LSIb = 102% ± 0%
Eccentric peak torque, 299 ± Eccentric peak torque, 249 ± Eccentric peak torque, 256 ±
12 Nm 40 Nm 15 Nm
Hamstrings Hamstrings Hamstrings
Peak torque, 138 ± 4 Nm Peak torque, 106 ± 7 Nm Peak torque, 93 ± 7 Nm
Peak torque per BW, 1.78 ± –0.10 Peak torque per BW, 1.62 ± –0.05 Peak torque per BW, 1.33 ± –0.01
Nm/kg Nm/kg Nm/kg
D/ND LSIb = 102% ± 3% D/ND LSIb = 102% ± 0% D/ND LSIb = 101% ± 4%
Eccentric peak torque, 187 ± Eccentric peak torque, 154 ± Eccentric peak torque, 162 ±
19 Nm 1 Nm 4 Nm
Eccentric peak torque per BW, Ratios Ratios
2.60 ± –0.26 Nm/kg HQRe = 62% ± 6% HQRe = 68% ± 6%
Ratios DCRc = 101% ± 3% DCRc = 126% ± 5%
HQRe = 60% ± 3%
DCRc = 75% ± 3%
Table continues on page 146.

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 [ literature review ]

Quadriceps and Hamstrings Strength Reference Values From Healthy
TABLE 2
Soccer Players2,6,9-12,14,15,17,20,21,24,29,33,34,39,41,44-46,48,51,55,56,59,62 (continued)

Isokinetica Isometrica
Sex/Sport Level Populationa 60°/s 180°/s 300°/s 90°
Nonelite n = 10 adolescents Quadriceps Quadriceps
Age, 17.8 ± 0.1 y29 Peak torque, 125 ± 15 Nm Peak torque, 90 ± 15 Nm
Peak torque per BW, 2.05 ± –0.20 Peak torque per BW, 1.50 ± –0.20
Nm/kg Nm/kg
Hamstrings Hamstrings
Peak torque, 105 ± 7 Nm Peak torque, 70 ± 5 Nm
Peak torque per BW, 1.70 ± –0.10 Peak torque per BW, 1.15 ± –0.05
Nm/kg Nm/kg
Ratio Ratio
HQRe = 86% ± 7% HQRe = 82% ± 10%
n = 106 young Quadriceps Quadriceps Quadriceps
adults Peak torque, 225 ± 0 Nm Peak torque, 150 ± 3 Nm Peak torque, 125 ± 5 Nm
Age, 23.5 ± 1.5 Peak torque per BW, 2.76 ± –0.41 Hamstrings Peak torque per BW, 1.27 ± –0.23
y10,11,48,56 Nm/kg Peak torque, 105 ± 7 Nm Nm/kg
D/ND LSIb = 106% ± 1% Ratio D/ND LSIb = 106%d
Eccentric peak torque, 310 ± HQRe = 71% ± 8% Hamstrings
10 Nm Peak torque, 90 ± 7 Nm
Eccentric peak torque per BW, Peak torque per BW, 0.98 ± –0.19
2.69 ± –0.45 Nm/kg Nm/kg
Hamstrings D/ND LSIb = 114%d
Peak torque, 130 ± 5 Nm Ratio
Peak torque per BW, 1.57 ± –0.23 HQRe = 79% ± 1%
Nm/kg
D/ND LSIb = 106% ± 6%
Eccentric peak torque, 150 ±
10 Nm
Eccentric peak torque per BW,
1.56 ± –0.35 Nm/kg
Ratios
HQRe = 61% ± 3%
DCRc = 71% ± 7%
Female
Elite n = 213 young Quadriceps Quadriceps
adults Peak torque, 149 ± 3 Nm Peak torque, 83 ± 12 Nm
Age, 21.3 ± 0.6 y2,44 Peak torque per BW, 2.32 ± –0.36 Hamstrings
Nm/kg Peak torque, 60 ± 9 Nm
D/ND LSIb = 101%d Ratio
Hamstrings HQRe = 72% ± 11%
Peak torque, 87 ± 1 Nm
Peak torque per BW, 1.36 ± –0.21
Nm/kg
D/ND LSIb = 103%d
Ratio
HQRe = 59% ± 1%
Nonelite n = 101 young Quadriceps Quadriceps
adults Peak torque, 88 ± 15 Nm Peak torque, 60 ± 10 Nm
Age, 20.3 ± 4.1 y39 D/ND LSIb = 101%d D/ND LSIb = 101%d
Abbreviations: BW, body weight; D, dominant; DCR, dynamic control ratio; HQR, hamstrings-quadriceps ratio; LSI, limb symmetry index; MVIC, maximum
voluntary isometric contraction; ND, nondominant.
a
Values are mean ± SD unless otherwise indicated.
b
Calculated as [(dominant leg)/(nondominant leg) × 100%].
c
A ratio of eccentric hamstrings strength to concentric quadriceps strength.
d
Standard deviation was not available.
e
A ratio of concentric hamstrings strength to concentric quadriceps strength.

146 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

sports (volleyball, hockey, futsal, Ameri- 7, 9, and 10 months after ACLR for 816 soccer, basketball, and handball), sexes,
can football, Australian football, judo, pivoting-sport athletes with ACLR (80% sport participation levels, and age groups.
alpine skiing, and modern ballet) were male) who were 21.8 ± 3.0 years of age. We aim for the reference values to help
grouped with unspecified pivoting sports After 7 months, strength values for ath- guide clinicians regarding what is normal
in TABLE 5. Strength results from other letes with ACLR were comparable to strength for pivoting-sport athletes, and
pivoting sports were reported in 11 stud- those of healthy pivoting-sport athletes. what to expect during rehabilitation and
ies.1,2,4,10,13,26,36-38,42,63 There were data from RTS progressions after ACLR.
1566 pivoting-sport athletes (92% male) DISCUSSION
who were 21.7 ± 1.9 years of age. Strength Testing Modes

W
Pivoting-Sport Athletes With e aimed to synthesize and Isokinetic dynamometry is the gold
ACLR  Strength results from 6 studies present reference values for quad- standard for strength tests. We chose to
of pivoting-sport athletes with ACLR at riceps and hamstrings strength report reference values at 60°/s, 180°/s,
a specific time point during rehabilita- tests for pivoting-sport athletes with and and 300°/s. This was based on a recent
tion were combined in TABLE 6.8,25,28,37,56,61 without ACLR. We presented separate re- Delphi study, in which experts (physical
Strength tests were completed at 3, 4, 6, sults for types of pivoting sport (including therapists, orthopaedic surgeons, and

Quadriceps and Hamstrings Strength Reference Values
TABLE 3
From Healthy Basketball Players16,29,33,47

Isokinetica
Sex/Sport
Level Populationa 60°/s 180°/s 300°/s
Male
Elite n = 73 young adults Quadriceps Quadriceps Quadriceps
Age, 22.7 ± 0.6 y33,47 Peak torque, 289 ± 3 Nm Peak torque, 190 ± 12 Nm Peak torque, 147 ± 27 Nm
Peak torque per BW, 3.21 ± –0.47 Nm/kg Peak torque per BW, 1.73 ± –0.31 Nm/kg Hamstrings
D/ND LSIb = 105%c D/ND LSIb = 98%c Peak torque, 82 ± 19 Nm
Hamstrings Hamstrings Ratio
Peak torque, 157 ± 8 Nm Peak torque, 107 ± 7 Nm HQRd = 56% ± 10%
Peak torque per BW, 2.06 ± –0.35 Nm/kg Peak torque per BW, 1.45 ± –0.27 Nm/kg
D/ND LSIb = 107%c D/ND LSIb = 100%c
Ratio Ratio
HQRd = 55% ± 3% HQRd = 58% ± 9%
Female
Elite n = 14 young adults Quadriceps Quadriceps Quadriceps
Age, 24.4 ± 2.6 y16 Peak torque, 185 ± 15 Nm Peak torque, 120 ± 10 Nm Peak torque, 75 ± 10 Nm
Peak torque per BW, 2.50 ± –0.15 Nm/kg Peak torque per BW, 1.70 ± –0.08 Nm/kg Peak torque per BW, 1.20 ± –0.08 Nm/kg
Hamstrings Hamstrings Hamstrings
Peak torque, 100 ± 10 Nm Peak torque, 55 ± 5 Nm Peak torque, 30 ± 4 Nm
Peak torque per BW, 1.50 ± –0.8 Nm/kg Peak torque per BW, 0.90 ± –0.06 Nm/kg Peak torque per BW, 0.50 ± –0.08 Nm/kg
Ratio Ratio Ratio
HQRd = 57% ± 9% HQRd = 55% ± 10% HQRd = 51% ± 10%
Nonelite n = 12 young adults Quadriceps Quadriceps
Age, 20.1 ± 0.4 y29 Peak torque, 105 ± 8 Nm Peak torque, 60 ± 5 Nm
Peak torque per BW, 1.90 ± –0.20 Nm/kg Peak torque per BW, 1.05 ± –0.10 Nm/kg
Hamstrings Hamstrings
Peak torque, 75 ± 7 Nm Peak torque, 47 ± 7 Nm
Peak torque per BW, 1.40 ± –0.10 Nm/kg Peak torque per BW, 0.85 ± –0.08 Nm/kg
Ratio Ratio
HQRd = 69% ± 15% HQRd = 78% ± 8%
Abbreviations: BW, body weight; D, dominant; HQR, hamstrings-quadriceps ratio; LSI, limb symmetry index; ND, nondominant.
a
Values are mean ± SD unless otherwise indicated.
b
Calculated as [(dominant leg)/(nondominant leg) × 100%].
c
Standard deviation was not available.
d
A ratio of concentric hamstrings strength to concentric quadriceps strength.

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | 147

 [ literature review ]
scientists) recommended a protocol of Strength Tests During Rehabilitation rehabilitation, it is possible to strive for
concentric knee extension and flexion After ACLR strength values comparable to those of
testing, including 5 repetitions at 60°/s, Because RTS is a continuous process that healthy pivoting-sport athletes as soon
20 repetitions at 180°/s, and 15 repeti- starts from the beginning of rehabilita- as 7 months after ACLR.56
tions at 300°/s, with 60 seconds of rest tion, it is important to evaluate strength
between sets.50 multiple times throughout rehabilita- Strength Tests as Part of the RTS Decision
Isokinetic dynamometry is unfortu- tion.5,53 Regular testing allows for easy Return-to-sport decisions after ACLR
nately only accessible for a small propor- modification of strength training pro- should be based on a battery of tests.3
tion of clinicians, due to its nonportability grams, tailored to the athlete’s strength However, the specific content of such a
and high cost.52 training status and needs. The reference battery is the subject of ongoing and stri-
When isokinetic dynamometry is values from our scoping review may help dent debate. Conflicting research in the
not available, (belt-stabilized) hand- guide goal setting and evaluation during ACL field compounds a complex debate.
held dynamometry can be a reliable al- rehabilitation, and guide clinicians to One key issue is that some studies include
ternative for measuring quadriceps and ideal and realistic expectations. Although athletes who do not return to pivoting
hamstrings strength.23,27 Handheld dy- reference values during rehabilitation are sports—a main confounder when inter-
namometry strength measurements can reported for 3, 4, 6, 7, 9, and 10 months preting the results, because not returning
be compared to MVIC reference values in post surgery, approximately 2 months to pivoting sports almost eliminates the
our scoping review. However, the MVIC are needed between measurements to risk for a second ACL injury.58 Therefore,
reference values in our review are all observe clinically meaningful changes.5 when reading studies about the associa-
measured with isokinetic dynamometry, There are, of course, individual differ- tion between RTS tests and second ACL
and the validity of handheld dynamom- ences in how fast athletes make mean- injuries, one should be aware of this.
etry measurements, when judged against ingful progress, but it is important not When eliminating the confounding fac-
isokinetic dynamometry measurements, to test too little or too often in order to tor of pivoting-sport participation, quad-
remains debated.23,35 keep athletes motivated. With adequate riceps strength test results are associated

Quadriceps and Hamstrings Strength Reference Values
TABLE 4
From Healthy Handball Players2,16,31,44

Isokinetica
Sex/Sport
Level Populationa 60°/s 180°/s 300°/s
Male
Elite n = 17 young adults Quadriceps Quadriceps
Age, 25.9 ± 4.1 y2 Peak torque, 266 ± 51 Nm Peak torque, 181 ± 36 Nm
Hamstrings Hamstrings
Peak torque, 163 ± 18 Nm Peak torque, 113 ± 22 Nm
Ratio Ratio
HQRb = 63% ± 12% HQRb = 63% ± 9%
Female
Elite n = 293 young adults Quadriceps Quadriceps Quadriceps
Age, 21.1 ± 0.9 y2,16,31,44 Peak torque, 169 ± 5 Nm Peak torque, 110 ± 7 Nm Peak torque, 91 ± 16 Nm
Peak torque per BW, 2.44 ± –0.05 Nm/kg Peak torque per BW, 1.70 ± –0.08 Nm/kg Peak torque per BW, 1.10 ± –0.08 Nm/kg
D/ND LSIc = 100%d Hamstrings Hamstrings
Hamstrings Peak torque, 40 ± 7 Nm Peak torque, 53 ± 18 Nm
Peak torque, 95 ± 2 Nm Peak torque per BW, 0.90 ± –0.06 Nm/kg Peak torque per BW, 0.50 ± –0.06 Nm/kg
Peak torque per BW, 1.38 ± –0.02 Nm/kg Ratio Ratio
D/ND LSIc = 103%d HQRb = 55% ± 10% HQRb = 61% ± 5%
Ratio
HQRb = 57% ± 1%
Abbreviations: BW, body weight; D, dominant; HQR, hamstrings-quadriceps ratio; LSI, limb symmetry index; ND, nondominant.
a
Values are mean ± SD unless otherwise indicated.
b
A ratio of concentric hamstrings strength to concentric quadriceps strength.
c
Calculated as [(dominant leg)/(nondominant leg) × 100%].
d
Standard deviation was not available.

148 | march 2022 | volume 52 | number 3 | journal of orthopaedic & sports physical therapy

with ACL and knee reinjuries and cannot to the expected quadriceps and ham- weight. When these metrics are unavail-
be denied as an important part of an RTS strings strength values for an individual able, peak torque or MVIC values are the
test battery.3,18,19,30 athlete. Besides peak torque and MVICs best alternative.
for torque, peak torque normalized to Besides using absolute reference val-
Clinical Relevance BW and MVICs normalized to BW are ues, it is important to consider using an
If preinjury values are unavailable for in- reported as absolute reference values. LSI. However, because the LSI-D/ND is
jured athletes or previous-season values We suggest using peak torque normal- used for reporting differences between
are unavailable for healthy athletes, cli- ized to BW and MVIC normalized to BW the dominant leg and the nondominant
nicians could choose to use the reference for comparing between athletes, because leg in healthy pivoting-sport athletes, we
tables from our scoping review as a guide they better account for the athlete’s body advise clinicians to use the same measure

Quadriceps and Hamstrings Strength Reference Values From
TABLE 5
Other Healthy Pivoting-Sporta Athletes1,2,4,10,13,26,36-38,42,63

Isokineticb Isometricb
Sex/Sport
Level Populationb 60°/s 180°/s 300°/s 70°
Male
Elite n = 20 adolescents Quadriceps Quadriceps
Age, 17.0 ± 0.54 Peak torque per BW, 3.42 ± –0.40 Peak torque per BW, 1.92 ± –0.20
Nm/kg Nm/kg
D/ND LSIc = 99%d D/ND LSIc = 102%d
Hamstrings Hamstrings
Peak torque per BW, 1.63 ± –0.16 Peak torque per BW, 1.27 ± –0.17
Nm/kg Nm/kg
D/ND LSIc = 103%d D/ND LSIc = 102%d
Ratio Ratio
HQRe = 48% ± 6% HQRe = 67% ± 12%
n = 1361 young Quadriceps Quadriceps Quadriceps Quadriceps
adults Peak torque, 309 ± 3 Nm Peak torque per BW, 2.52 ± –0.28 Peak torque, 136 ± 40 Nm MVIC per BW, 417 ± 56
Age, 22.5 ± 1.2 Peak torque per BW, 2.89 ± –0.03 Nm/kg Peak torque per BW, 1.93 ± –0.07 N/kg
y2,4,26,36,38,63 Nm/kg Hamstrings Nm/kg Hamstrings
D/ND LSIc = 102% ± 0% Peak torque per BW, 1.75 ± –0.27 D/ND LSIc = 103%d MVIC per BW, 186 ± 24
Hamstrings Nm/kg TW, 1813 ± 480 J (15 reps; range, N/kg
Peak torque, 208 ± 3 Nm Ratio 90°) Ratio
Peak torque per BW, 1.94 ± –0.01 HQRe = 70% ± 9% TW D/ND LSIc = 102%d HQRe = 45%d
Nm/kg Hamstrings
D/ND LSIc = 101% ± 0% Peak torque, 94 ± 29 Nm
Ratio Peak torque per BW, 1.29 ± –0.05
HQRe = 68% ± 1% Nm/kg
D/ND LSIc = 104%d
TW, 1596 ± 486 J (15 reps; range,
90°)
TW D/ND LSIc = 99%d
Ratio
HQRe = 68% ± 1%
Nonelite n = 61 young adults Quadriceps Quadriceps
Age, 23.7 ± 0.4 y10,37 Peak torque per BW, 2.70 ± –0.18 Peak torque per BW, 1.33 ± –0.25
Nm/kg Nm/kg
D/ND LSIc = 105% ± 3% D/ND LSIc = 106%d
Hamstrings Hamstrings
Peak torque per BW, 1.58 ± –0.04 Peak torque per BW, 0.86 ± –0.23
Nm/kg Nm/kg
D/ND LSIc = 102% ± 2% D/ND LSIc = 106%d
Ratio Ratio
HQRe = 55% ± 10% HQRe = 65% ± 15%
Table continues on page 150.

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 [ literature review ]

Quadriceps and Hamstrings Strength Reference Values From Other
TABLE 5
Healthy Pivoting-Sporta Athletes1,2,4,10,13,26,36-38,42,63 (continued)

Isokineticb Isometricb
Sex/Sport
Level Populationb 60°/s 180°/s 300°/s 70°
Female
Elite n = 34 young adults Quadriceps Quadriceps Quadriceps
Age, 21.0 ± 0.0 y2,26 Peak torque, 180 ± 42 Nm Peak torque, 87 ± 18 Nm MVIC per BW, 396 ± 45
Hamstrings Hamstrings N/kg
Peak torque, 92 ± 18 Nm Peak torque, 62 ± 11 Nm Hamstrings
Ratio Ratio MVIC per BW, 166 ± 22
HQRe = 53% ± 10% HQRe = 72% ± 10% N/kg
Ratio
HQRe = 42%d
Nonelite n = 53 adolescents Ratio Ratio
Age, 19.4 ± 1.3 y13 HQRe = 63% ± 8% HQRe = 74% ± 15%
n = 37 young adults Quadriceps Quadriceps Quadriceps
Age, 22.6 ± 1.5 y1,42 Peak torque, 123 ± 8 Nm Peak torque, 86 ± 5 Nm Peak torque, 61 ± 8 Nm
Peak torque per BW, 2.27 ± –0.27 Peak torque per BW, 1.60 ± –0.22 Peak torque per BW, 1.20 ± –0.15
Nm/kg Nm/kg Nm/kg
Hamstrings Hamstrings Hamstrings
Peak torque, 0.49 ± –0.10 Nm Peak torque, 39 ± 8 Nm Peak torque, 30 ± 7 Nm
Peak torque per BW, 0.96 ± –0.22 Peak torque per BW, 0.73 ± –0.17 Peak torque per BW, 0.58 ± –0.14
Nm/kg Nm/kg Nm/kg
Abbreviations: BW, body weight; D, dominant; HQR, hamstrings-quadriceps ratio; LSI, limb symmetry index; MVIC, maximum voluntary isometric contrac-
tion; ND, nondominant; reps, repetitions; TW, total work.
a
Sports included volleyball, hockey, futsal, American football, Australian football, judo, alpine skiing, and modern ballet.
b
Values are mean ± SD unless otherwise indicated.
c
Calculated as [(dominant leg)/(nondominant leg) × 100%].
d
Standard deviation was not available.
e
A ratio of concentric hamstrings strength to concentric quadriceps strength.

for supporting pivoting-sport athletes liers in each set of athletes, as reference oting-sport athletes, it has not yet been
with ACLR when they are making RTS values are based on a Gaussian curve. investigated whether there is an associa-
decisions. The LSI-D/ND between the We used broad selection criteria to tion between meeting reference values
dominant and nondominant legs ranged maximize generalizability. However, due and sustaining a second ACL injury.
from 98% to 114% in healthy athletes. to sparse data in the group of athletes
We suggest that clinicians use this as a with ACLR, we were not able to present CONCLUSION
benchmark for pivoting-sport athletes separate results for different graft types.

W
with ACLR instead of an LSI greater than Graft type can affect strength at differ- e synthesized and present ab-
90%, as often advised.32 ent stages of rehabilitation. Therefore, solute quadriceps and hamstrings
When athletes with ACLR do not we suggest interpreting reference values strength reference values for
meet the expected absolute values and for pivoting-sport athletes with ACLR as pivoting-sport athletes with and without
have an LSI between the dominant and minimum requirements and striving for ACLR. Data from 42 articles are orga-
nondominant legs below the healthy higher values earlier in the rehabilitation nized by type of sport (eg, soccer, basket-
reference, consider additional strength process. It is probably better to use these ball, handball), sex, sport participation
training before return to pivoting sports. reference values together with reference level, and age group. In addition to using
values from healthy pivoting-sport ath- absolute reference values, the LSI be-
Limitations letes, because we do not have insight into tween dominant and nondominant legs
We provided an extensive and detailed postoperative rehabilitation protocols. is valuable to use for RTS decisions. This
overview of quadriceps and hamstrings Although we present these strength LSI between dominant and nondominant
strength absolute and LSI reference val- test reference values to help clinicians legs ranged from 98% to 114% in healthy
ues. However, there will always be out- judge what “normal” strength is for piv- athletes. t

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Quadriceps and Hamstrings Strength Reference Values for Pivoting-
TABLE 6
Sport Athletes During Rehabilitation After ACLR8,25,28,37,56,61

Isokinetica Isometrica
Time Point/
Sex/Sport
Level Population,a Graft Type 60°/s 180°/s 300°/s 45°
3 mo
Male
Nonelite n = 156 adolescents; Quadriceps
age, 18.8 ± 3.1 y25 O-leg peak torque per BW, 1.41 ± –0.44
Quadriceps Nm/kg
NO-leg peak torque per BW, 2.46 ±
–0.58 Nm/kg
LSIb = 58% ± 17%
Hamstrings
O-leg peak torque per BW, 1.18 ± –0.36
Nm/kg
NO-leg peak torque per BW, 1.40 ±
–0.48 Nm/kg
LSIb = 86% ± 19%
Female
Nonelite n = 164 adolescents; Quadriceps
age, 17.4 ± 2.8 y25 O-leg peak torque per BW, 1.13 ± 0.54
Quadriceps Nm/kg
NO-leg peak torque per BW, 2.28 ±
–0.42 Nm/kg
LSIb = 48% ± 16%
Hamstrings
O-leg peak torque per BW, 0.93 ± –0.27
Nm/kg
NO-leg peak torque per BW, 1.20 ±
–0.31 Nm/kg
LSIb = 79% ± 22%
4 mo
Male
Elite n = 20 young adults; Quadriceps Quadriceps Quadriceps
age, 24.2 ± 5.1 y28 O-leg peak torque, 101 ± 35 Nm O-leg peak torque, 84 ± 22 Nm O-leg MVIC, 142 ± 48 N
BPTB NO-leg peak torque, 176 ± 38 Nm NO-leg peak torque, 126 ± 26 Nm NO-leg MVIC, 213 ± 55 N
LSIb = 57%c LSIb = 67%c LSIb = 67%c
Hamstrings Hamstrings Hamstrings
O-leg peak torque, 92 ± 24 Nm O-leg peak torque, 76 ± 17 Nm O-leg MVIC, 107 ± 21 N
NO-leg peak torque, 107 ± 21 Nm NO-leg peak torque, 85 ± 17 Nm NO-leg MVIC, 105 ± 26 N
LSIb = 86%c LSIb = 89%c LSIb = 102%c
Nonelite n = 38 young adults; Quadriceps
age, 24.2 ± 4.7 y56 O-leg peak torque, 189 ± 52 Nm
BPTB and hamstrings O-leg peak torque per BW, 2.40 ±
–0.50 Nm/kg
NO-leg peak torque, 262 ± 58 Nm
NO-leg peak torque per BW, 3.30 ±
–0.50 Nm/kg
LSIb = 72% ± 12%
Hamstrings
O-leg peak torque, 128 ± 31 Nm
NO-leg peak torque, 143 ± 31 Nm
LSIb = 89% ± 14%
Table continues on page 152.

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 [ literature review ]

Quadriceps and Hamstrings Strength Reference Values for Pivoting-
TABLE 6
Sport Athletes During Rehabilitation After ACLR8,25,28,37,56,61 (continued)

Isokinetica Isometrica
Time Point/
Sex/Sport
Level Population,a Graft Type 60°/s 180°/s 300°/s 45°
6 mo
Male
Elite n = 20 young adults; Quadriceps Quadriceps Quadriceps
age, 24.2 ± 5.1 y28 O-leg peak torque, 122 ± 37 Nm O-leg peak torque, 99 ± 31 Nm O-leg MVIC, 165 ± 40 N
BPTB NO-leg peak torque, 179 ± 40 Nm NO-leg peak torque, 129 ± 32 Nm NO-leg MVIC, 225 ± 50 N
LSIb = 68%c LSIb = 77%c LSIb = 73%c
Hamstrings Hamstrings Hamstrings
O-leg peak torque, 99 ± 24 Nm O-leg peak torque, 79 ± 16 Nm O-leg MVIC, 111 ± 21 N
NO-leg peak torque, 111 ± 21 Nm NO-leg peak torque, 84 ± 14 Nm NO-leg MVIC, 110 ± 22 N
LSIb = 89%c LSIb = 94%c LSIb = 101%c
Nonelite n = 156 adolescents; Quadriceps
age, 18.8 ± 3.1 y25 O-leg peak torque per BW, 2.03 ± –0.51
Quadriceps Nm/kg
NO-leg peak torque per BW, 2.79 ±
–0.56 Nm/kg
LSIb = 72% ± 15%
Hamstrings
O-leg peak torque per BW, 1.45 ± –0.34
Nm/kg
NO-leg peak torque per BW, 1.52 ±
–0.34 Nm/kg
LSIb = 95% ± 17%
n = 118 young adults; Quadriceps
age, 23.6 ± 5.8 y37 O-leg peak torque per BW, 2.00 ±
BPTB –0.45 Nm/kg
NO-leg peak torque per BW, 2.60 ±
–0.45 Nm/kg
LSIb = 77% ± 14%
Hamstrings
O-leg peak torque per BW, 1.46 ± –0.29
Nm/kg
NO-leg peak torque per BW, 1.51 ±
–0.28 Nm/kg
LSIb = 97% ± 12%
Female
Nonelite n = 164 adolescents; Quadriceps
age, 17.4 ± 2.8 y25 O-leg peak torque per BW, 1.61 ± –0.45
Quadriceps Nm/kg
NO-leg peak torque per BW, 2.53 ±
–0.45 Nm/kg
LSIb = 63% ± 16%
Hamstrings
O-leg peak torque per BW, 1.22 ± –0.25
Nm/kg
NO-leg peak torque per BW, 1.35 ±
–0.31 Nm/kg
LSIb = 91% ± 18%

Table continues on page 153.

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Quadriceps and Hamstrings Strength Reference Values for Pivoting-
TABLE 6
Sport Athletes During Rehabilitation After ACLR8,25,28,37,56,61 (continued)

Isokinetica Isometrica
Time Point/
Sex/Sport
Level Population,a Graft Type 60°/s 180°/s 300°/s 45°
7 mo
Male
Nonelite n = 60 young adults; Quadriceps Quadriceps Quadriceps
age, 25.8 ± 2.3 y56,61 O-leg peak torque, 223 ± 51 Nm LSIb = 80% ± 12% LSIb = 82% ± 11%
BPTB and hamstringsd O-leg peak torque per BW, 2.90 ± Hamstrings Hamstrings
–0.50 Nm/kg LSIb = 102% ± 11% LSIb = 102% ± 27%
NO-leg peak torque, 267 ± 58 Nm
NO-leg peak torque per BW, 3.30 ±
–0.50 Nm/kg
LSIb = 85% ± 13%
Hamstrings
O-leg peak torque, 144 ± 30 Nm
NO-leg peak torque, 149 ± 34 Nm
LSIb = 98% ± 8%
9 mo
Male
Nonelite n = 298 young adults; Quadriceps
age, 24.2 ± 4.6 y8 O-leg peak torque per BW, 2.24 ± –0.47
BPTB, hamstrings, and Nm/kg
quadriceps LSIb = 84% ± 14%
Hamstrings
O-leg peak torque per BW, 1.53 ± –0.29
Nm/kg
LSIb = 97% ± 14%
10 mo
Male
Nonelite n = 38 young adults; Quadriceps
age, 24.2 ± 4.7 y56 O-leg peak torque, 257 ± 51 Nm
BPTB and hamstrings O-leg peak torque per BW, 3.20 ±
–0.60 Nm/kg
NO-leg peak torque, 270 ± 61 Nm
NO-leg peak torque per BW, 3.40 ±
–0.50 Nm/kg
LSIb = 94% ± 15%
Hamstrings
O-leg peak torque, 150 ± 31 Nm
NO-leg peak torque, 153 ± 34 Nm
LSIb = 98% ± 8%
Abbreviations: ACLR, anterior cruciate ligament reconstruction; BPTB, bone-patellar tendon-bone; BW, body weight; LSI, limb symmetry index; MVIC, maxi-
mum voluntary isometric contraction; NO, nonoperated; O, operated.
a
Values are mean ± SD unless otherwise indicated.
b
Calculated as [(operated leg)/(nonoperated leg) × 100%].
c
Standard deviation was not available.
d
At 60°/s, BPTB and hamstrings; at 180°/s and 300°/s, BPTB.

KEY POINTS mon pivoting sports (including soccer, for healthy pivoting-sport athletes, and
FINDINGS: Detailed reference values are basketball, and handball). what to expect during rehabilitation and
presented for athletes with and without IMPLICATIONS: Quadriceps and hamstrings return-to-sport (RTS) progressions after
anterior cruciate ligament reconstruc- strength test reference values help clini- ACLR.
tion (ACLR) who play the most com- cians judge what “normal” strength is CAUTION: The association between meet-

journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | 153

 [ literature review ]
ing reference values and (safe) RTS after review. Br J Sports Med. 2019;53:1154-1161. can reduce reinjury risk by 84% after ACL recon-
ACLR requires more study. https://doi.org/10.1136/bjsports-2018-099982 struction: the Delaware-Oslo ACL cohort study.
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the article. All authors contributed to at 9 months after surgery. Orthop J Sports string injury prediction among professional male
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journal of orthopaedic & sports physical therapy | volume 52 | number 3 | march 2022 | 155

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