Are lower limb symmetry and self-reported symptoms associated with functional and neuromuscular outcom

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Journal of Bodywork & Movement Therapies 38 (2024) 168–174
Available online 24 December 2023
1360-8592/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Are lower limb symmetry and self-reported symptoms associated with 
functional and neuromuscular outcomes in Brazilian adults with anterior 
cruciate ligament reconstruction? A cross-sectional study 
Natália Cristina Azevedo Queiroz a, Tânia Cristina Dias da Silva Hamu c, Saulo 
Delfino Barboza d,e,f, Silvio Assis de Oliveira-Junior g, Rodrigo Luiz Carregaro a,b,* 
a Master in Rehabilitation Sciences, Universidade de Brasília (UnB), Campus UnB Ceilândia, Brasília, Brazil 
b Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands 
c Physiotherapy Department, Musculoskeletal Research Laboratory (LAPEME), State Universidade Estadual de Goiás (UEG), Goiânia Campus, Brazil 
d Master Program on Health & Education, University of Ribeirao Preto, Sao Paulo, Brazil 
e Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam Universities Medical Centers, VU University Medical Center 
Amsterdam, Amsterdam, the Netherlands 
f Amsterdam Collaboration on Health and Safety in Sports, Amsterdam Movement Sciences, Amsterdam Universities Medical Centers, VU University Medical Center 
Amsterdam, Amsterdam, the Netherlands 
g School of Physical Therapy, Universidade Federal de Mato Grosso do Sul (UFMS), Mato Grosso do Sul, Brazil 
A R T I C L E I N F O 
Handling Editor: Dr Jerrilyn Cambron 
Keywords: 
Knee 
Movement 
Rehabilitation 
Muscle strength 
Anterior cruciate ligament 
A B S T R A C T 
Introduction: After anterior cruciate ligament (ACL) reconstruction, determining readiness to return to partici-
pation is challenging. The understanding of which neuromuscular performance parameters are associated with 
limb symmetry and self-reported symptoms may be useful to improve monitoring the rehabilitation towards 
adequate decision-making to return. 
Objectives: To compare the ACL-operated and injury-free lower limbs regarding functional performance; and to 
investigate whether lower limb strength and functional performance are associated with self-reported symptoms 
and functional lower limb symmetry. 
Method: Thirty-four participants were included. Functional performance was assessed by using the Y-Balance test, 
Single-leg Hop, and Functional Movement Screen. An isokinetic dynamometer was used to evaluate the strength 
levels in open and closed kinetic chains. The functional lower limb symmetry was calculated considering the 
single-leg hop test results for each lower limb. 
Results: There were no differences in dynamic balance (Y-Balance) between the operated and injury-free limbs. 
The operated limb presented a worst performance in the single-leg hop. Self-reported symptoms prevalence and 
lower limb symmetry were associated with knee extension strength and functional performance (Y-Balance). 
Conclusion: Individuals submitted to ACL-reconstruction presented worse functional performance in the operated 
limb compared to the injury-free limb. Both knee strength and dynamic balance were associated with limb 
symmetry and self-reported symptoms. 
1. Introduction 
Anterior cruciate ligament (ACL) rupture is the most common liga-
ment injury among musculoskeletal injuries that affect the knee joint 
(Lopes et al., 2016; Kaeding et al., 2017; Sepúlveda et al. 2017). About 
120,000 cases of ACL rupture are reported annually in the United States 
(Kaeding et al., 2017). In Brazil, there was an increase of 64% in the 
overall incidence, from 2.59 to 3.49 cases per 100,000 people/year, 
between 2008 and 2014 (Lopes et al., 2016). Such an increase raised the 
public direct healthcare costs due to ACL reconstruction surgeries, 
demonstrating a healthcare cost of US$ 56 million (Lopes et al., 2016). 
Because ACL rupture can result in chronic instability of the knee 
* Corresponding author: Vrije Universiteit Amsterdam, MF Building, Faculty of Science, Health Sciences, Van der Boechorststraat 7, 1081 BT, Amsterdam, The 
Netherlands. 
E-mail address: r.luizcarregaro@vu.nl (R. Luiz Carregaro). 
Contents lists available at ScienceDirect 
Journal of Bodywork & Movement Therapies 
journal homepage: www.elsevier.com/jbmt 
https://doi.org/10.1016/j.jbmt.2023.12.002 
Received 28 December 2021; Received in revised form 19 September 2023; Accepted 12 December 2023 
mailto:r.luizcarregaro@vu.nl
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Journal of Bodywork & Movement Therapies 38 (2024) 168–174
169
joint, surgical interventions are widely used (Bispo et al., 2008). 
Although a systematic review (Ardern et al. 2014) demonstrated that 
around 65% of individuals return to the pre-injury functionality level 
after reconstruction, those with objective knee function classified as 
abnormal, or severely abnormal, have a lower chance of returning to 
daily activities or sports. Moreover, individuals presenting previous ACL 
tears have a 6-fold increased risk of a second injury within two years of 
surgery (Paterno 2015). 
Poor performance in dynamic balance and single-leg hop tests (Myer 
et al., 2009; Garrison et al., 2015) and asymmetric functional perfor-
mance (Gribble et al., 2012; Myers et al., 2018) were associated with a 
higher risk of ACL injury. Moreover, individuals that underwent ACL 
reconstruction have differences in strength between the operated limb 
and the injury-free one (Kim et al., 2016; Machado et al., 2018; Prill 
et al. 2019), and asymmetries between the limbs in the biomechanics of 
landing in an early (mean of 10 months) and later postoperative period 
(mean of 3 years) (Webster et al., 2021). These aspects demonstrate the 
importance of restoring muscle strength and functional symmetry after 
ACL reconstruction (Buckthorpe et al., 2019), as the deficit can remain 
even after the return to activities (Lisee et al., 2019), and might persist 
for more than two years after the ACL reconstruction (Petersen et al. 
2014). 
The rehabilitation of ACL reconstruction needs to work towards 
achieving satisfactory outcomes related to neuromuscular strength and 
functional performance (Ardern et al. 2014). This is relevant because 
from a clinical standpoint, determining the patient’s readiness to return 
to pre-surgery daily activities and return to participation is still chal-
lenging (Nawasreh et al., 2018). Time-related criteria are frequently 
used to determine readiness for returning to sports and pre-injury per-
formance, ranging from less than 6 months to more than 12 months after 
ACL reconstruction (Burgi et al., 2019). Nevertheless, the establishment 
of clinical outcomes that are associated with neuromuscular function 
and self-reported symptoms could be more helpful to guide clinician’s 
interventions and the decision whether to return (Werner et al., 2018; 
Aquino et al., 2020). 
Therefore, we raise a question whether muscle strength changes in 
different kinematic conditions are associated with lower self-reported 
symptoms scores and presence of functional limb asymmetry and 
movement quality in the phase of return to participation (i.e.,aims of the present study were: 1) to compare the 
ACL-operated and injury-free lower limbs regarding functional perfor-
mance; and 2) to investigate whether lower limb strength and functional 
performance are associated with higher scores of self-reported symp-
toms and lower limb symmetry. We hypothesize that muscle strength 
levels in different kinematic conditions are directly associated with 
scores of self-reported symptoms and limb asymmetry. 
2. Method 
2.1. Study design and participants 
This is an observational study with cross-sectional design. The par-
ticipants were selected by convenience via referral from clinics 
specialized in ACL reconstruction surgery in the city of Goiânia, Brazil, 
during October 2017 until February of 2018. The sample size was 
calculated based on a fixed linear multiple regression model, consid-
ering an effect size of 0.45, α of 5%, power (1 - β) of 80%, and limited to 
five possible predictors. The calculation resulted in a total sample size of 
32 participants. 
The inclusion criteria were: patients from 18 to 40 years-old, with 
clinical and image diagnosis of ACL rupture (Benjaminse et al., 2006; 
Blanke et al., 2020), regardless of sex; who have been submitted to 
ligament reconstruction using the hamstring tendon autograft, and were 
in the 4th month post-ACL reconstruction, which is considered the phase 
of return to participation (i.e., less than 6 months post-ACL recon-
struction) (Ardern et al., 2016; Goes et al., 2020). We chose the fourth 
postoperative month to investigate our aims, because in this period, 
deficits are still observed in strength tests (Nicol et al., 2001), but the 
graft is in an advanced phase of healing (Janssen and Scheffler 2014). 
The ACL-reconstruction surgeries were performed by two surgeons 
using the same technique (hamstring tendon autograft). 
Participants were excluded if they had current bilateral knee liga-
ment injuries, fractures of any kind in the lower limbs; had history of 
osteoarthrosis in the patellofemoral or tibiofemoral joints with evident 
joint axis deviation, and considerable diagnosed comorbidity, such as 
neoplasms; or if they were pregnant. All participants were invited to 
participate by signing the Informed Consent Form, approved by the 
Ethics Committee (Campus UnB Ceilândia, protocol no. 
64041316.4.0000.8093). 
2.2. Data collection 
Data collection was performed by a trained and experienced phys-
iotherapist via questionnaires and functional assessments. A question-
naire recorded personal characteristics and clinical data (i.e., sex, age, 
weight, height, knee diagnosis, duration of physiotherapy interventions, 
and return to physical activities - e.g., gym, sports, work). 
2.3. Self-report symptoms 
The International Knee Documentation Committee Questionnaire 
(IKDC) was applied to assess self-reported symptoms, function during 
daily activity, and the level of symptom-free sports activity (Irrgang 
et al., 2001; Greco et al., 2010). The scores range from 0 to 100 points, 
with higher scores representing lower levels of symptoms and higher 
levels of function and sports activity (Irrgang et al., 2001). 
2.4. Functional performance 
Functional performance was assessed using the Y-Balance Test (YBT) 
(Gribble et al., 2012), the Single-leg Hop Test (SLHT) (Magalhães et al., 
2016), and the Functional Movement Screening (FMS) (Cook et al. 
2014). All participants were allowed one familiarization session with the 
YBT and SLHT before the actual tests were performed. The familiar-
ization was characterized by verbal instructions and three practice trials 
in each test, with an interval of 10 s between trials. Both tests (YBT and 
SLHT) were performed in the order described below after 10 min rest 
between each other. 
The YBT is a valid measure of dynamic balance, and can quantify 
balance deficits (Gribble et al., 2012). The test is performed on single-leg 
support (assessed limb) while the other lower limb reaches three di-
rections: anterior, posterolateral, and posteromedial. Participants were 
instructed to touch the ground as far as possible with the foot of the 
non-evaluated limb while maintaining a single leg stance with the 
evaluated one, and then return the reaching foot to the center. All par-
ticipants were instructed to remain with their hands placed on their hips 
to prevent interference by the upper limbs (Appendix 1). 
The assessor manually measured the distance from the target’s 
center to the reached point with a measuring tape (Robinson and Gribble 
2008). Three attempts were made at each direction, and the mean value 
was used for analysis. The distances (in centimeters) were normalized by 
the leg length of each participant (distance reached by the leg/length of 
the reaching lower limb) x 100, (Gribble et al., 2012) which was 
measured as the distance between the anterosuperior iliac spine and the 
medial malleolus, in supine position (Neelly et al., 2013). 
The SLHT assesses functional performance throughout propulsion, 
N.C.A. Queiroz et al. 
Journal of Bodywork & Movement Therapies 38 (2024) 168–174
170
hop, and landing on the ground, which is related to strength and pro-
prioception of the lower limb (Magalhães et al., 2016). The test was 
performed on each limb (operated and non-injured). Two 6-m-long ad-
hesive tapes were placed on the ground, separated from each other at a 
distance of 15 cm. Participants were instructed to perform the hop for-
ward with the hands facing backward, as far as possible. Three attempts 
were made with each leg and the mean was used for analysis. 
The FMS consists of seven movements involving actions of the trunk, 
arms, and lower limbs: deep squat, hurdle step, in-line lunge, shoulder 
mobility, active straight-leg raise, trunk stability push-up, and rotary 
stability. These movements allow the assessment of muscle strength, 
joint stability in different movement planes, joint flexibility, and balance 
(Narducci et al., 2011; Cook et al. 2014). An experienced certified 
examiner (N.A.Q.) was responsible for conducting the test. The score for 
each movement ranges from 1 (movement with deficits) to 3 (perfect 
execution of the movement). The assessment is based on the movement 
quality, presence of asymmetries, and difficulties in completing each 
movement. The score “0″ is applied when there is pain and the test is 
stopped. The final score is calculated by the sum of the scores of each 
movement and ranges from 7 to 21 (Cook et al. 2014). Participants were 
allowed to perform three attempts for each movement, and the best 
attempt of each movement was used for analysis. 
2.5. Lower limb symmetry 
Data from the SLHT were used to calculate the limb symmetry index 
(LSI). The LSI measurement was based on the following equation: 
(operated limb SLHT score/injury-free limb SLHT score) x 100. Based on 
the LSI, the individuals were stratified in reference to the following 
cutoff score: LSI ≥90% and LSIrest interval was adopted. 
The OKC test consisted of knee flexion and extension. The range of 
motion was set from maximum flexion to maximum extension for each 
participant, in which the reference point was 90◦of flexion. The 
Fig. 1. Isokinetic dynamometer test in closed kinetic chain: A) flexion and B) extension (the arrows indicate the direction of the movement); and open kinetic chain: 
C) Flexion and D) Extension. 
N.C.A. Queiroz et al. 
Journal of Bodywork & Movement Therapies 38 (2024) 168–174
171
dynamometer chair was positioned at 90◦, with an inclination at 0◦, and 
the chair positioned in such a way that the hip was at 70-85◦of flexion. 
The movement axis of the equipment was aligned with the lateral 
intercondylar space. The axis of rotation of the lever arm was positioned 
in reference to the line of the lateral condyle of the femur, with a range 
of motion ranging from 90◦ to 30◦ (for calibration purposes, 0◦ was 
established as complete knee extension). Prior to the test, a 5-min warm- 
up was performed on an exercise bike (50W load-light). Subsequently, 
participants were stabilized with straps wrapped around the trunk, 
abdomen, and non-assessed thigh. The bilateral isokinetic protocol 
established was for concentric contractions at 60◦/s and 300◦/s, with 5 
and 15 repetitions, respectively (Cavalcante et al., 2016). 
For the CKC test, the dynamometer chair was adjusted until the 
popliteal fossa of the knee was rested on the inferior portion of the seat. 
The rotation axis was aligned with the lateral epicondyle of the femur 
(initial position at 45◦ of knee and hip flexion). The back of the chair was 
at 90◦and the lever arm was adjusted and fixed 2 cm above the ankle’s 
malleoli (Fig. 1). Participants were instructed not to move the ankle 
(plantar flexion and dorsiflexion) and were stabilized with straps over 
the trunk, pelvis, and over the thigh, avoiding the contribution of upper 
limbs and pelvic retroversion. The protocol was the same as the OKC, at 
60◦/s and 300◦/s with a single set of 5 and 15 repetitions, respectively. 
Neuromuscular function and muscle strength in both OKC and CKC 
were quantified by the peak torque by body weight in extension (EPT/ 
BW) and in flexion (FPT/BW), both expressed in percentage. The 
agonist/antagonist ratio was calculated by dividing the peak torque of 
the antagonist’s muscle by the agonist and presented as a percentage 
(Cavalcante et al., 2016). 
2.7. Statistical analysis 
The Shapiro-Wilk test was applied to verify the data normality as-
sumptions. Categorical variables were described in absolute frequency 
(n) and proportions (%); continuous numerical variables were presented 
as mean and standard deviation (SD). Regarding body mass index (BMI), 
for description purposes, participants were categorized as eutrophic 
(18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (higher 
than or equal to 30 kg/m2) (Weir and Jan 2020). 
The paired Student’s t-test was adopted to compare the variables YBT 
and SLHT between the operated and injury-free limbs of the 
participants. 
A linear regression with a stepwise model was conducted to inves-
tigate how well muscle strength in closed and open kinetic chains (EPT/ 
BW, FPT/BW, and Agonist/Antagonist ratio), FMS, YBT, and single-leg 
hop test measurements (independent variables) could be associated 
with the scores of LSI and IKDC (dependent variables). For the stepwise 
method, the variable selection was automatically entered or removed 
based on the significance (P 0.90) (Bohannon 1992). Variables with collinearity (r > 0.7) were 
removed from the model. The significance was set at 5% (Plower limbs of individuals 
submitted to ACL reconstruction regarding functional performance. We 
also investigated if muscle strength and performance could predict self- 
reported symptoms and limb symmetry. There were no differences in the 
dynamic balance between ACL-reconstructed and injury-free lower 
limbs; however, scores were lower for the operated limb in the single-leg 
hop test (SLHT). We confirmed our initial hypothesis, given that self- 
reported symptoms and limb symmetry index (LSI) were associated 
with a set of neuromuscular outcomes. 
Self-reported knee symptoms presented a score lower than 90 for all 
participants, which does not necessarily indicate readiness to return to 
physical activities (Toole et al., 2017). However, although the return to 
sports 4 months after ACL reconstruction is not considered common 
(Burgi et al., 2019), some of our participants had returned to some ac-
tivities (e.g., gym and sports). This is in line with Goes et al. (2020), 
indicating that the period between 12 and 24 weeks includes the return 
to activity and transition to sports. Nevertheless, this finding was not 
expected and raised some concerns given that one of the requirements 
for an adequate rehabilitation discharge is at least the recovery of 
quadriceps muscle strength, which was able to explain 66% of the 
variance in self-reported symptoms in individuals with ACL injury 
(Pietrosimone et al., 2013). Previous studies have demonstrated the 
importance of self-reported symptoms as a criterion for return to sport 
and physical activities (Werner et al., 2018; Aquino et al., 2020), and 
that increases in quadriceps strength were associated with better sub-
jective knee function (Bodkin et al., 2020). We assume that a better 
condition should have been identified pertaining to self-reported knee 
symptoms, as we found worst scores compared to a study that also 
assessed individuals at the fourth month of post-ACL reconstruction 
(Bodkin et al., 2020). This is relevant because the participants who had 
returned to their physical activities might be at risk of recurrence. 
Asymmetric performances at the YBT were considered valid to pre-
dict the risk of lower limb injuries (Gribble et al., 2012), corroborating 
our regression findings. Also, Myers et al. (2018) found that individuals 
with an asymmetry of more than 4 cm in the anterior direction showed 
deficits of approximately 30% in muscle strength. Although we did not 
find significant differences between the operated and injury-free limbs 
in the YBT, our findings suggest some level of success in the rehabili-
tation process followed by the participants. There was an average 
difference of 5.7 cm in the posterolateral direction and 2.4 cm in the 
anterior direction. Some individuals presented asymmetries of up to 
14.6 cm and 5.7 cm in the lateral and anterior direction (respectively, as 
shown by the confidence intervals). Such findings may indicate a poor 
dynamic balance, which requires attention by clinicians given that 
asymmetries in YBT can also affect performance in activities such as 
jumping (Fort-Vanmeerhaeghe et al., 2020). 
Participants’ performance in the single-leg hop was worse in the 
operated limb compared to the injury-free limb. Our results are similar 
to previous studies (King et al., 2019; Peebles et al., 2019) and suggest 
an incomplete recovery, which poses an additional risk of recurrence. 
Delahunt et al. (2012) demonstrated that poor performance in hop tests 
is often correlated with worse functionality. As participants were in the 
fourth postoperative month, better functional performance could have 
been expected. However, Castanharo et al. (2011) demonstrated that 
asymmetries during the single-leg hop in individuals that underwent 
ACL reconstruction can be present even after two years of returning to 
daily activities. This finding highlights the need to integrate other 
measures as criteria for discharge from rehabilitation. 
Self-reported symptoms and lower limb symmetry were associated 
with a set of variables related to functional performance and strength in 
both open and closed chains. These variables explained, respectively, 
15% and 39% of the variance in the symptoms and LSI. The study by 
Nawasreh et al. (2018) demonstrated that performance in the single-leg 
hop test is an important predictor for the return to activities after 12 and 
24 months in individuals who underwent ACL reconstruction. The au-
thors also demonstrated that normal knee function and movement 
symmetry between limbs during functional tasks at 6 months after ACL 
reconstruction determined the return to the same pre-injury activity 
level. These findings are relevant because, in many situations, in-
dividuals perform physical activities that require the execution of spe-
cific tasks such as take-off, pivoting, and landing maneuvers, which are 
replicated to some extent by the single-leg hop. Our findings are also 
corroborated by Ithurburn et al. (2019), which investigated what clin-
ical measures are associated with functionality and should be addressed 
during post-surgical rehabilitation. The greater the muscle strength and 
the better the symmetry of strength between the lower limbs, the better 
the knee symptoms were in a period of up to two years after returning to 
sports (Ithurburn et al., 2019). 
We found that muscle strength in closed chain and dynamic balance 
were significantly associated with lower limb symmetry. In addition, 
15% of the self-reported symptoms were explained by muscle strength in 
open chain. This is interesting because Bodkin et al. (2020) demon-
strated that strength assessments at 4 months post-ACL reconstruction 
may be informative to clinicians regarding strength deficits that may 
need to be addressed. Moreover, quadriceps muscle strength in the pre 
and postoperative moments can influence the functional results after 
ACL reconstruction, and individuals with more strength prior to return 
might substantially reduce the reinjury rate (Eitzen et al., 2009, 
Grindem et al., 2016; Bodkin et al., 2020; Maestroni et al., 2020). Closed 
chain movements can be considered determinants for better limb sym-
metry, balance, and adequate movement (Begalle et al. 2012; Dedinsky 
et al., 2017), which is important as such assessments of muscle strength, 
symmetry and functional performance during rehabilitation can guide 
decision-making regarding return to activities (Hartigan et al., 2012; 
Toole et al., 2017). In closed chain, the muscle co-contraction provides 
greater joint stability, in addition to being similar to some functional 
movements (Lam and Ng 2001). Begalle et al. (2012) demonstrated that 
closed chain movements (e.g., single-leg deadlift exercise), which was 
similar to the protocol adopted in our study with the isokinetic equip-
ment, provided greater activation of the hamstrings and, consequently, 
more balanced agonist/antagonist ratios. This is in line with Andrade 
et al. (2020), demonstrating that early full weight-bearing exercises (i.e., 
as early as four weeks after surgery) with open and closed kinetic chain 
exercises were recommended in the rehabilitation during the ACL 
postoperative phase. Furthermore, the contribution of strength variables 
Table 3 
Regression analysis for the self-reported symptoms (IKDC: International Knee 
Documentation Committee - model 1), and limb symmetry index (LSI) score 
(Model 2), presenting the coefficients (B) and probability values (p). 
Regression model 1 - IKDC 
R 0.38 
R2 15% 
B CI95% p-value 
Constant 51.3 37.4; 65.3 - 
EPT/BW/op/60◦.s− 1/OKC 0.127 0.015; 0.239 0.028 
Regression model 2 - LSI 
R 0.63 
R2 39% 
B CI95% p-value 
Constant 73.5 64.1; 82.8 - 
EPT/BW/ijf/300◦.s− 1/CKC 0.276 − 0.134; 0.418di-
rection in the injury-free limb. 
N.C.A. Queiroz et al. 
Journal of Bodywork & Movement Therapies 38 (2024) 168–174
173
in closed chain is also of clinical value to establish the functional con-
dition required to achieve a limb symmetry higher than 90%, as rec-
ommended in an evidence-based clinical guideline (van Melick et al., 
2016). Regarding the self-reported symptoms, we assume that other 
variables related to psychological and contextual aspects might play a 
significant role, as recommended by a previous review (Burgi et al., 
2019). This is interesting because, besides symptoms, clinicians should 
consider patient’s expectations and other aspects related to activity and 
participation (e.g., specific sports or daily activity demands, and social 
interaction) (Ardern et al., 2016) in order to decide the return to 
activities. 
Our study presented limitations. First, we adopted a cross-sectional 
design; therefore, we were limited regarding conclusions pertaining to 
prediction analysis. Second, the participants underwent ACL- 
reconstruction using the hamstring tendon autograft, hence we cannot 
generalize our findings to other surgical techniques (Maestroni et al., 
2020). In addition, we did not include the objective analysis of the knee 
anterior laxity, which could influence the results of the single-leg hop 
and strength tests after ACL reconstruction. Third, other factors could be 
associated with the neuromuscular function and strength of individuals 
who underwent ACL reconstruction, such as the specificity of sports and 
physical activities practice (e.g., measures of participation and context), 
intensity and frequency of physical exercise, and anatomical differences 
in bone structures and cartilages (Burgi et al., 2019; Hiranaka et al., 
2019). 
5. Conclusion 
Our findings showed that individuals in the fourth month after ACL 
reconstruction surgery did not present deficits in dynamic balance 
compared to their injury-free limbs. However, the operated limb showed 
worse functional performance in the single-leg hop test. Knee extensor 
strength, and dynamic balance, were associated with limb symmetry 
and self-reported symptoms. This is relevant for clinical practice, as 
functional tests are easily reproducible and might be useful to monitor 
and identify characteristics that indicate better self-reported symptoms 
and lower limb symmetry in the early phase of ACL reconstruction 
rehabilitation. 
6. Clinical relevance 
• Knee strength assessments at 4-months post-ACL reconstruction 
might be helpful to determine self-reported symptoms and lower 
limb symmetry; 
• Self-reported symptoms should be considered as a criterion for early- 
return after ACL-reconstruction rehabilitation; 
• Performance in the single-leg hop was worse in the operated limb 
compared to the injury-free limb, suggesting incomplete recovery at 
4-months post-ACL reconstruction. 
Funding 
This study was financed in part by Coordenação de Aperfeiçoamento 
de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001; and 
Universidade de Brasília (UnB/DPI). 
CRediT authorship contribution statement 
Natália Cristina Azevedo Queiroz: Conceptualization, Data cura-
tion, Investigation, Methodology. Tânia Cristina Dias da Silva Hamu: 
Conceptualization, Data curation, Formal analysis, Writing – original 
draft, Writing – review & editing. Saulo Delfino Barboza: Validation, 
Visualization, Writing – original draft, Writing – review & editing. Silvio 
Assis de Oliveira-Junior: Methodology, Supervision, Validation, 
Visualization, Writing – original draft, Writing – review & editing. 
Rodrigo Luiz Carregaro: Conceptualization, Data curation, 
Supervision, Validation, Visualization, Writing – original draft, Writing 
– review & editing. 
Declaration of competing interest 
None to declare. 
Acknowledgments 
The authors would like to thank Marcelo Torres, Halley Paranhos, 
Helder Rocha, and Ulbiramar Correia for referring participants to the 
study. 
Appendix A. Supplementary data 
Supplementary data to this article can be found online at https://doi. 
org/10.1016/j.jbmt.2023.12.002. 
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	Are lower limb symmetry and self-reported symptoms associated with functional and neuromuscular outcomes in Brazilian adult ...
	1 Introduction
	2 Method
	2.1 Study design and participants
	2.2 Data collection
	2.3 Self-report symptoms
	2.4 Functional performance
	2.5 Lower limb symmetry
	2.6 Neuromuscular function and muscle strength
	2.7 Statistical analysis
	3 Results
	4 Discussion
	5 Conclusion
	6 Clinical relevance
	Funding
	CRediT authorship contribution statement
	Declaration of competing interest
	Acknowledgments
	Appendix A Supplementary data
	References