Kneeling difficulty is common following anterior cruciate ligament reconstruction with hamstring autograft and correlates with outcome measures

Nicholas D. Calvert, Anne Smith, Tim Ackland, Markus S. Kuster, Jay Ebert

Research output: Contribution to journalArticlepeer-review

7 Citations (Scopus)


Introduction: Patients frequently have discomfort or difficulty with kneeling following anterior cruciate ligament reconstruction (ACLR). This study aimed to report the prevalence of, and reasons for, kneeling difficulty after ACLR with a hamstring autograft; and to investigate the association between the degree of kneeling difficulty, presence of concurrent meniscal surgery, and clinical outcomes, including patient-reported outcome measures (PROMs) and functional tests. Materials and methods: A total of 104 patients undergoing ACLR with ipsilateral hamstring autograft were enrolled. Participants completed a kneeling difficulty questionnaire and other PROMs including the International Knee Documentation Committee (IKDC) questionnaire, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Cincinnati Knee Rating System (CKRS), the Lysholm Knee Scoring Scale (LKS), the Tegner Activity Scale (TAS), the 36-Item Short Form Health Survey (SF-36), and the Knee Outcome Survey (KOS). Patients were also assessed objectively via peak isokinetic knee extensor and flexor strength, range of movement (ROM), and functional hop tests. Results: The prevalence of kneeling difficulty on the operated knee was 77% and 54% at 1 and 2 years after ACLR, respectively. Strong associations were observed between kneeling difficulty and PROMs, ranging from CKRS at 1 year of r = 0.403 (95% CI 0.228–0.553, p <0.001) to KOS at 2 years of r = 0.724 (95% CI 0.618, 0.804, p <0.001). No associations were observed with age, body mass index, or knee ROM measures. Weak-to-moderate associations were demonstrated with functional hop tests. The degree of kneeling difficulty did not differ with concurrent meniscal surgery. Conclusions: Kneeling difficulty occurs in as much as 77% of patients following ACLR with hamstring grafts at 1 year, and 54% at 2 years. This has a moderate-to-very strong association with patient-reported assessment of knee pain, symptoms, sport and recreation, and knee-related quality of life. There appears to be no association with patient age, BMI, time from injury to surgery, knee ROM, or concurrent meniscal surgery. Level of evidence: IV

Original languageEnglish
Pages (from-to)913-921
Number of pages9
JournalArchives of Orthopaedic and Trauma Surgery
Issue number7
Publication statusPublished - 1 Jul 2020


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