The Feasibilty of the Motor Control Home Ergonomics Elderlies' Prevention of Falls (McHeELP) Programme in Patients with Sarcopenia: A Pilot Study.

Objectives: The objective of this pilot study was to investigate the feasibility of a three month 'Motor control Home ergonomics Elderlies' Prevention of falls' (McHeELP) programme on muscle mass, muscle strength, functionality, balance and fear of falling among older adults with sarcopenia. Methods: A feasibility study of the McHeELP programme was performed in patients with sarcopenia. Primary outcome measures included number of participants; number of participants that showed engagement with the programme; adherence rates; data loss in questionnaires and secondary outcome measures; any adverse events, related or not to the intervention programme. All participants received a home-based motor control exercise programme combined with an ergonomic home modification for 12 weeks. Secondary outcome measures included Hand Grip Strength, Bioimpendance Analysis, Muscle Mass, Functionality and Fear of Falling. Results: Twelve participants, (74.9±5 years), completed the pilot study. Significant differences were recorded before and after the programme on participants' functionality (p < 0.001), balance (p < 0.05) and fear of falling (p < 0.001). Conclusions: The present study revealed that the McHeELP programme is fesasible and that it is possible to implement the programme in clinical practice. The McHeELP programme positively affects functionality, balance and fear of falling. Thus, it seems feasible to conduct a full-scale randomised controlled trial.

Inter-Rater and Test-Retest Reliability of an Innovative Evaluation Tool: CrossFit Functional Assessment Battery of Tests for the Shoulder Joint.

Background and objectives This study aims to introduce an innovative functional assessment tool designed for CrossFit athletes, to identify a high risk of injury at the shoulder joint. Additionally, the study seeks to examine both inter-rater reliability, which was tested in 40 CrossFit participants, and test-retest reliability, which was assessed in twenty subjects. Methodology CrossFit Functional Assessment Battery for the Shoulder Joint (CrossFit FABS) is a newly created instrument presented for the first time. The evaluation of the performance of its six items aimed to reveal deficits that could contribute to incidents of shoulder injuries. For this purpose, 40 healthy CrossFit participants were concurrently but independently examined by two raters, and twenty healthy adults active in sports were assessed by the main investigator at two different time points. Cohen's kappa coefficient was used to analyze categorical data with an ordinal structure. Results Inter-rater reliability ranged from 0.824 to 1 (P = 0.000) and test-retest reliability was 0.661 to 0.906 (P < 0.001) for each test of CrossFit FABS. A strong to almost perfect correlation was demonstrated for all the variables between the two examiners. Moderate to almost perfect correlation was shown through test-retest procedures. Conclusions The proposed test battery was established as a reliable tool for evaluating performance routines that represent high injury-risk elements for the shoulder joint in CrossFit athletes.

Diastasis Recti Abdominis Rehabilitation in the Postpartum Period: A Scoping Review of Current Clinical Practice.

INTRODUCTION AND HYPOTHESIS: Despite exercise being the standard approach to diastasis recti abdominis (DRA) rehabilitation, there is no consensus on the most effective exercise routine and adjunct modalities for reducing DRA and improving functional parameters. The present study is aimed at investigating evidence for DRA rehabilitation in postpartum women, as well as knowledge gaps and areas for future research. METHODS: For this scoping review a systematic search was conducted in MEDLINE, AMED, CINAHL, Embase, ScienceDirect, Scopus, and PEDro up to November 2022. Selection criteria included studies investigating exercise therapy interventions both with and without adjunct modalities for postpartum DRA. Sample characteristics, diagnostic criteria, program design, and outcome measures were recorded. Critical appraisal of clinical trials was performed using PEDro classification. RESULTS: Twenty-eight studies were included: 14 clinical trials, 3 case series, and 11 observational studies. DRA exercises that focused on deep and superficial muscles, pelvic floor muscles, respiratory maneuvers, functional exercises, or alternative interventions (yoga, suspension training, hypopressive exercise) and adjunct modalities showed promising results in reducing the inter-recti distance and related dysfunction. However, there was great variability in diagnostic criteria and methods, DRA severity, time post-birth, and exercise program design. CONCLUSIONS: Reviewed studies provide valuable insights into exercise therapy, but it is important to recognize their limitations, as variability in diagnostic criteria, sample characteristics, and exercise program design hinder the generalizability of the findings. Further high-quality research is needed to strengthen the evidence in this area and provide reliable recommendations for clinical practice.

Towards the Development of a System Dynamics Model for the Prediction of Lower Extremity Injuries.

Acute noncontact Lower Extremity (LE) injuries constitute a significant problem in team sports. Despite extensive research, current knowledge on the risk factors of LE injuries is limited to static simplistic models of instantaneous cause and effect relationships ignoring the time dimension and the embedded complexity of LE injuries. Even though complex systems approaches have been used in various cases to improve policy and intervention effectiveness, there is limited research on predicting and managing LE injuries. This creates an opportunity to fill the gap in the current literature by applying the System Dynamics (SD) methodology to model LE injuries. The proposed approach allows for synthesizing risk factors and examining their interaction. This paper makes the first step towards such an approach by developing a causal loop model revealing the etiology of LE injuries. A causal loop model for LE injuries is developed via an extensive literature review and brainstorming with experts. In contrast to the traditional static approaches, the proposed model reveals some of the complexity and nonlinear relationships of the various sports injury risk factors. The derived causal loop model may then be used to quantify these interactions and develop a simulation model. This will be achieved by operationalizing and incorporating the main risk factors that impact LE injuries in an integrated sports injury prediction model. In this way, plausible strategies for preventing LE injuries can be tested prior implementation and thereby achieve optimization of intervention programs.

Risk factors for Achilles tendon rupture: an updated systematic review.

OBJECTIVE: Identifying risk factors for Achilles Tendon Rupture (ATR) is one of the first necessary steps for its prevention. This systematic review aimed to update the systematic review published in 2014 in ATR etiology. METHODOLOGY: A systematic review was carried out using PubMed, EBSCO, and ScienceDirect databases. All types of research studies (Randomized Control Trials - RCTs, Cohort studies, Case-control studies and Cross-sectional studies) that considered ATR, were eligible. The inclusion criteria for eligibility of the studies were to be written in the English language, and to include populations of men and/or women, both athletes, and non-athletes, healthy individuals, and patients. Two independent reviewers used the assessment instrument Newcastle-Ottawa Scale independently, to evaluate the quality of each selected study. Further, two reviewers worked independently to extract the study characteristics, and the GRADE methodology was used to assess the level of certainty of each risk factor. RESULTS: From 9526 studies initially identified, 19 studies were eligible for further analysis to identify risk factors for ATR. Seventeen studies were considered good quality, and two studies fair quality. Low to very low certainty of evidence was found for the following medications: steroids, quinolones, and oral bisphosphonate, as well as for other factors such as chronic tendon inflammation and Achilles' tendinopathy, spring season, diabetes, previous musculoskeletal injury, regular participation in athletic activity, hyperparathyroidism, renal failure, and genetic factors. CONCLUSIONS: The risk factors found prove that ATR is a multifactorial injury. Appropriate methodologies and well-designed studies are needed to determine the factors and their significance in ATR risk. Finally, the role of biomechanical and psychological aspects in the ATR etiology may be of interest in future studies, as we could not extract relative data in our review.

Low-Load Resistance Training With Blood Flow Restriction Is Effective for Managing Lateral Elbow Tendinopathy: A Randomized, Sham-Controlled Trial.

OBJECTIVE: To evaluate the effect of low-load resistance training with blood flow restriction (LLRT-BFR) when compared to LLRT with sham-BFR in patients with lateral elbow tendinopathy (LET). DESIGN: Randomized controlled trial. METHODS: Forty-six patients with LET were randomly assigned to a LLRT-BFR or a LLRT with sham-BFR treatment group. All patients received soft tissue massage, supervised exercises with BFR or sham intervention (twice a week for 6 weeks), advice, and a home exercise program. The primary outcome measures were pain intensity, patient-rated tennis elbow evaluation (PRTEE) score, pain-free grip strength, and global rating of change, measured at baseline, 6 weeks, and 12 weeks. Between-group differences were evaluated using mixed-effects models with participant-specific random effects for continuous data. Global rating of change was analyzed using logistic regression. RESULTS: Statistically significant between-group differences were found in favor of LLRT-BFR compared to LLRT with sham-BFR in pain intensity at 12-week follow-up (-1.54, 95% CI: -2.89 to -0.18; P = .026), pain-free grip strength ratio at 6-week follow-up (0.20, 95% CI: 0.06 to 0.34; P = .005), and PRTEE at 6- and 12-week follow-up (-11.92, 95% CI: -20.26 to -3.59; P = .006, and -15.23, 95% CI: -23.57 to -6.9; P<.001, respectively). At 6- and 12-weeks, patients in the LLRT-BFR group had greater odds of reporting complete recovery or significant improvement (OR = 6.0, OR = 4.09, respectively). CONCLUSION: Low-load resistance training with blood flow restriction produced significantly better results compared to the LLRT with sham-BFR for all primary outcomes. Considering the clinically significant between-group improvement in function (>11 points in PRTEE) and the better success rates in the LLRT-BFR group, this intervention may improve recovery in LET. J Orthop Sports Phys Ther 2022;52(12):803-825. Epub: 14 September 2022. doi:10.2519/jospt.2022.11211.

The Effect of Body Position and the Reliability of Upper Limb Arterial Occlusion Pressure Using a Handheld Doppler Ultrasound for Blood Flow Restriction Training.

BACKGROUND: The precise calculation of arterial occlusive pressure is essential to accurately prescribe individualized pressures during blood flow restriction training. Arterial occlusion pressure in the lower limb varies significantly between different body positions while similar reports for the upper limb are lacking. HYPOTHESIS: Body position has a significant effect in upper limb arterial occlusive pressure. Using cuffs with manual pump and a handheld Doppler ultrasound can be a reliable method to determine upper limb arterial blood flow restriction. STUDY DESIGN: A randomized repeated measures design. LEVEL OF EVIDENCE: Level 3. METHODS: Forty-two healthy participants (age mean ± SD = 28.1 ± 7.7 years) completed measurements in supine, seated, and standing position by 3 blinded raters. A cuff with a manual pump and a handheld acoustic ultrasound were used. The Wilcoxon signed-rank test with Bonferroni correction was used to analyze differences between body positions. A within-subject coefficient of variation and an intraclass correlation coefficient (ICC) test were used to calculate reproducibility and reliability, respectively. RESULTS: A significantly higher upper limb arterial occlusive pressure was found in seated compared with supine position (P < 0.031) and in supine compared with standing position (P < 0.031) in all raters. An ICC of 0.894 (95% CI = 0.824-0.939, P < 0.001) was found in supine, 0.973 (95% CI = 0.955-0.985, P < 0.001) in seated, and 0.984 (95% CI = 0.973-0.991, P < 0.001) in standing position. ICC for test-retest reliability was found 0.90 (95% CI = 0.814-0.946, P < 0.001), 0.873 (95% CI = 0.762-0.93, P < 0.001), and 0.858 (95% CI = 0.737-0.923, P < 0.001) in the supine, seated, and standing position, respectively. CONCLUSION: Upper limb arterial occlusive pressure was significantly dependent on body position. The method showed excellent interrater reliability and repeatability between different days. CLINICAL RELEVANCE: Prescription of individualized pressures during blood flow restriction training requires measurement of upper limb arterial occlusive pressure in the appropriate position. The use of occlusion cuffs with a manual pump and a handheld Doppler ultrasound showed excellent reliability; however, the increased measurement error compared with the differences in arterial occlusive pressure between certain positions should be carefully considered for the clinical application of the method. STRENGTH OF RECOMMENDATIONS TAXONOMY (SORT): B.

Physiotherapists' Perceptions and Willingness to Use Telerehabilitation in Greece: A Cross-Sectional Study.

Introduction Coronavirus disease 2019 (COVID-19) has affected the healthcare system and the practice of physiotherapists. Telerehabilitation is an alternative method of delivering physiotherapy services. The aim of this study was to investigate physiotherapists' knowledge, beliefs, and willingness to use telerehabilitation in Greece during the COVID-19 pandemic. Materials and methods In this cross-sectional study, Greek physiotherapists completed an online survey between January and February 2022. A questionnaire was distributed via the Panhellenic Physiotherapy Association (PSF). The questionnaire involved 26 items on demographic background, use of technology, overall perceptions, the experience of telerehabilitation, and their opinion on the future of telerehabilitation. The study protocol was approved by the Ethical Committee of the University of Patras, Greece. Results Participants in this study were 213 physiotherapists (female 57.7%; mean age 39.84±8 years). Most physiotherapists (n=118; 55.4%) were working in a private clinic in the areas of outpatient orthopedics, geriatrics, and neurorehabilitation. Overall, most participants (55%) reported increased use of telerehabilitation strategies during the COVID-19 pandemic. A total of 130 physiotherapists (n=61.3%) believed that telerehabilitation may be beneficial as a supplementary way of patient management. Greek physiotherapists made use of low-cost and easily accessible digital technologies, such as mobile phones and online meeting tools (e.g., Skype, Zoom). Although most physiotherapists (79.8%) reported that they wanted to receive more information about digital technology and telerehabilitation, only 42.1% of them did intend to work remotely after the pandemic. Conclusion Most of the participants were willing to deliver physiotherapy via telerehabilitation. Specific education and training programs need to be provided to physiotherapists during and after the pandemic. Healthcare managers should consider the use of telerehabilitation and design guidelines and policies to manage telerehabilitation practices in Greece.

Evaluating the Effects of Match-Induced Fatigue on Landing Ability; the Case of the Basketball Game.

This paper examines the effect of match-induced fatigue on lower limb biomechanics, in the case of a basketball game. For this purpose, sixteen male basketball athletes, ages 18 to 22, performed a jump-landing task prior and post a recreational basketball game. The Landing Error Scoring System (LESS) was used to examine the biomechanics of landing. The Vertical jump (VJ) and the Borg Rating of Perceived Exertion (RPE) scale pre- and post-game were employed to assess the level of fatigue induced by the basketball game. In order to compare pre and post measurements, t-tests for dependent samples were used. The performance of the VJ test post-game was found to be significantly lower (t (15) = 3.83, p = 0.002) showing a large effect (Cohen's d = 0.9) compared to pre-game measurements. Further, the LESS scores were significantly (t (15) = 2.33, p = 0.034) higher post-game with a medium effect (d = 0.5). The differences in LESS scores were due to errors in the landing technique which is bound to be influenced by biomechanics. Moreover, the Borg RPE scale was found to be significantly higher (t (15) = 10.77, p < 0.001) postgame showing a very large effect (d =2.6). It is important to note, that these significant differences occurred with a merely medium level of fatigue (6.6 ± 0.3 pre-game vs 11.9 ± 1.0 post-game). The results of this study would be of great benefit to sports science teams and coaches for formulating effective strategies to improve athletes' performance and reduce the likelihood of injury.

Preseason functional testing in young basketball players: asymmetries and intercorrelations.

[Purpose] The present study aimed to examine the existence and degree of possible asymmetries of functional test performance and their intercorrelations in the lower extremities of young basketball players. [Participants and Methods] Twenty-seven healthy male basketball players (age: 15.52 ± 1.37 years) were examined for the symmetric function of their lower extremities using triple hop for distance tests in the sagittal and frontal plane (medial-lateral), the Y-balance test and a vertical jump test. [Results] Participants exhibited statistically significant side-to-side differences in only the medial triple hop test, as they jumped further on their non-dominant for stability lower limb. No other asymmetries were observed in the rest of the functional tests. Significant correlations were also indicated between the vertical jumptest and the three directions of the triple hop test for both lower limbs. [Conclusion] Our findings proved that young basketball players present a symmetrical picture of functional performance, as revealed by the evaluation of various functional tests. The only significant asymmetric adaptation observed in the medial triple hop test will have to be strengthened by future studies to be implemented in injury prevention programs.

The effectiveness of Ergon Instrument-Assisted Soft Tissue Mobilization, foam rolling, and athletic elastic taping in improving volleyball players' shoulder range of motion and throwing performance: a pilot study on elite athletes.

[Purpose] The purpose of this pilot study was to investigate the effectiveness of instrument-assisted soft tissue mobilization (IASTM), foam rolling, and athletic elastic taping on improving elite volleyball players' shoulder range of motion (ROM) and throwing performance. [Participants and Methods] Fifteen elite male volleyball players (mean age: 24 ± 4.54 years; mean height: 177 ± 0.08 cm; mean weight: 81 ± 7.71 kg) received shoulder Ergon IASTM, foam rolling, and elastic taping treatment in random order on both upper extremities once a week for three weeks. Pre-and post-treatment assessments of their shoulders' ROM and functional throwing performance were performed. [Results] Ergon IASTM technique resulted in significantly higher shoulder flexion ROM values than foam rolling and elastic taping. Foam rolling, in turn, showed better results than athletic elastic taping. Moreover, the Ergon IASTM technique resulted in significantly higher OSP values than athletic elastic taping. No significant differences were observed between the therapeutic interventions in terms of FTPI. [Conclusion] This pilot study on elite athletes provides evidence that both IASTM and foam rolling techniques may improve their passive shoulder ROM compared to elastic athletic taping while Ergon IASTM can also enhance their shoulder throwing performance.

Association of the Single-Limb Hop Test With Isokinetic, Kinematic, and Kinetic Asymmetries in Patients After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Asymmetries persist after anterior cruciate ligament reconstruction (ACLR). Physical performance tests such as the single-limb hop test have been used extensively to assess return-to-sport criteria, as they reproduce dynamic athletic maneuvers. HYPOTHESIS: The single-limb hop is associated with muscle strength and kinematic and kinetic asymmetries in ACLR patients 6 to 9 months after surgery. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-two men with ACLR (mean age, 28.8 ± 11.2 years) at 6 to 9 months (mean, 7.01 ± 0.93 months) after surgery completed isokinetic testing in 3 velocities (120, 180, and 300 deg/s) and a kinetic, kinematic, and functional evaluation of the single-limb hop test. Pearson correlation coefficients were used to assess the relationship between the Limb Symmetry Index (LSI) of the single-limb hop distance and each of the outcome variables. RESULTS: There were significant positive correlations between the LSI of the single-limb hop distance and the LSI of the peak extension torque at 120 deg/s (P = 0.044, r = 0.37) and the peak extension torque at 180 deg/s (P = 0.042, r = 0.38) as well as a negative correlation with the peak flexion torque at 180 deg/s (P = 0.043, r = -0.38). The LSI of the single-limb hop test was not correlated with any kinetic or kinematic variable (P > 0.05). CONCLUSION: The findings of the present study demonstrate that distance LSI of the single-limb hop test correlates with isokinetic extension peak torque LSI but not kinetic and kinematic asymmetry. CLINICAL RELEVANCE: The single-limb hop test can be used as an additional tool for the recognition of muscle strength asymmetries but not for kinetic or kinematic asymmetries 6 to 9 months after ACLR.

Asymmetries in functional hop tests, lower extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior cruciate ligament reconstruction.

STUDY DESIGN: Within-subject and between-subject cross-sectional study. OBJECTIVES: To investigate symmetry in hop-test performance, strength, and lower extremity kinematics 6 to 9 months following anterior cruciate ligament reconstruction (ACLR). BACKGROUND: Despite the extensive body of literature involving persons following ACLR, no study has comprehensively evaluated measures of strength, lower extremity kinematics, and functional performance of functional hop tests in this population. METHODS: The subjects were 22 men (mean ± SD age, 28.8 ± 11.2 years) who had ACLR using a bone-patellar tendon-bone autograft 6 to 9 (7.01 ± 0.93) months previously and 22 healthy male controls (age, 24.8 ± 9.1 years). Participants completed a self-report questionnaire and underwent isokinetic strength testing and functional and kinematic assessment of the single-, triple-, and crossover-hop tests. Two-way analyses of variance were used to test for differences between the ACLR group and the control group, and between the 2 lower extremities of the ACLR group. RESULTS: Compared to the control group, the ACLR group had greater isokinetic knee extension torque deficits at all speeds (P ≤.001) and greater performance asymmetry for all 3 hop tests (P<.001). Compared to the noninvolved lower extremity, the involved lower extremity of the ACLR group exhibited less ankle dorsiflexion and knee flexion in the phases of propulsion (P ≤.014) and landing (P ≤.032). When compared to the control group, the involved lower extremity exhibited less ankle dorsiflexion in the propulsion phase (P<.001) but higher hip flexion in the landing phase (P = .014). CONCLUSION: Six to 9 months following ACLR, patients continue to demonstrate functional hop and isokinetic knee extension deficits, as well as kinematic differences, during the propulsion and landing phases of the hop tests.

Lessons learned from the last 20 years of ACL-related in vivo-biomechanics research of the knee joint.

PURPOSE: Technological advances in recent years have allowed the easy and accurate assessment of knee motion during athletic activities. Subsequently, thousands of studies have been published that greatly improved our understanding of the aetiology, surgical reconstruction techniques and prevention of anterior cruciate ligament (ACL) injuries. The purpose of this review is to summarize the evidence from biomechanical studies on ACL-related research. METHODS: High-impact articles that enhanced understanding of ACL injury aetiology, rehabilitation, prevention and adaptations after reconstruction were selected. RESULTS: The importance of restoring internal tibial rotation after ACL reconstruction has emerged in several studies. Criteria-based, individualized rehabilitation protocols have replaced the traditional time-based protocols. Excessive knee valgus, poor trunk control, excessive quadriceps forces and leg asymmetries have been identified as potential high risk biomechanical factors for ACL tear. Injury prevention programmes have emerged as low cost and effective means of preventing ACL injuries, particularly in female athletes. CONCLUSION: As a result of biomechanical research, clinicians have a better understanding of ACL injury aetiology, prevention and rehabilitation. Athletes exhibiting neuromuscular deficits predisposing them to ACL injury can be identified and enrolled into prevention programmes. Clinicians should assess ACL-reconstructed patients for excessive internal tibial rotation that may lead to poor outcomes.

The influence of graft choice on isokinetic muscle strength 4-24 months after anterior cruciate ligament reconstruction.

PURPOSE: Regaining adequate strength of the quadriceps and hamstrings after anterior cruciate ligament (ACL) reconstruction is important for maximizing functional performance. However, the outcome of muscle strength after either BPTB or hamstrings autograft is unclear given the plethora of published studies that report post-operative muscle strength. The purpose of this study was to systematically compare the muscle strength of patients who have undergone ACL reconstruction using either Bone Patellar Tendon Bone (BPTB) or Hamstrings (HST) autograft. METHODS: The databases of MEDLINE, Cinahal and EMBASE were systematically searched for articles that report muscle strength outcome following ACL reconstruction. The quality of the studies was evaluated and a meta-analysis of the muscle strength outcomes was conducted on reported data. RESULTS: Fourteen studies were included in this systematic review: eight Randomized Control Studies (RCT) and six non-Randomized Control Studies (non-RCT). A meta-analysis was performed involving eight of the included studies (4 RCTs & 3 non-RCTs). At 60°/s and 180°/s, patients with BPTB graft showed a greater deficit in extensor muscle strength and lower deficit in flexor muscle strength compared with patients with HST. CONCLUSION: This systematic review of Level III evidence showed that isokinetic muscle strength deficits following ACL reconstruction are associated with the location of the donor site. These deficits appear to be unresolved up to 2 years after ACL reconstruction. LEVEL OF EVIDENCE: III.

Stride-to-stride variability is altered during backward walking in anterior cruciate ligament deficient patients.

BACKGROUND: Recently backward walking is used by physical therapists to strengthen the hamstring muscles and thus improve the function of the knee joint of anterior cruciate ligament deficient patients. The aim of this study was to examine the stride-to-stride variability of anterior cruciate ligament deficient patients during backward walking. The variation of how a motor behavior emerges in time is best captured by tools derived from nonlinear dynamics, for which the temporal sequence in a series of values is the facet of interest. METHODS: Fifteen patients with unilateral anterior cruciate ligament deficiency and eleven healthy controls walked backwards at their self-selected speed on a treadmill while three-dimensional knee kinematics were collected (100 Hz). A nonlinear measure, the largest Lyapunov Exponent was calculated from the resulted knee joint flexion-extension data of both groups to assess the stride-to-stride variability. FINDINGS: Both knees of the deficient patients exhibited significantly lower Lyapunov Exponent values as compared to the healthy control group revealing more rigid movement pattern. The intact knee of the deficient patients showed significantly lower Lyapunov Exponent values as compared to the deficient knee. INTERPRETATION: Anterior cruciate ligament (ACL) deficiency leads to loss of optimal variability regardless of the walking direction (forwards in previous studies or backwards here) as compared to healthy individuals. This could imply diminished functional responsiveness to the environmental demands for both knees of ACL deficient patients which could result in the knees being more susceptible to injury.