Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 2, pp 478–490 | Cite as

Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial

  • Tjerk ZultEmail author
  • Alli Gokeler
  • Jos J. A. M. van Raay
  • Reinoud W. Brouwer
  • Inge Zijdewind
  • Jonathan P. Farthing
  • Tibor Hortobágyi



Limited evidence suggests that cross-education affords clinical benefits in the initial 8 weeks after anterior cruciate ligament (ACL) reconstruction, but it is unknown if such cross-education effects are reproducible and still present in later phases of rehabilitation. We examined whether cross-education, as an adjuvant to standard therapy, would accelerate the rehabilitation up to 26 weeks after ACL reconstruction by attenuating quadriceps weakness.


ACL-reconstructed patients were randomized into experimental (n = 22) and control groups (n = 21). Both groups received standard care after ACL reconstruction. In addition, the experimental group strength trained the quadriceps of the non-operated leg during weeks 1–12 after surgery (i.e., cross-education). Self-reported knee function was assessed with the Hughston Clinic Knee score as the primary outcome. Secondary outcomes were maximal quadriceps and hamstring strength and single leg hop distance. All outcomes were measured 29 ± 23 days prior to surgery, as a reference, and at 5-week, 12-week, and 26-week post-surgery.


Both groups scored 12% worse on self-reported knee function 5-week post-surgery (95% CI 7–17) and showed 15% improvement 26-week post-surgery (95% CI − 20 to − 10). No cross-education effect was found. Interestingly, males scored 8–10% worse than females at each time point post-surgery. None of 33 secondary outcomes showed a cross-education effect. At 26-week post-surgery, both legs improved maximal quadriceps (5–14%) and hamstring strength (7–18%), and the non-injured leg improved 2% in hop distance. The ACL recovery was not affected by limb dominance and age.


26 weeks of standard care improved self-reported knee function and maximal leg strength relative to pre-surgery and adding cross-education did not further accelerate ACL recovery.

Level of evidence


Clinical Trial Registry name and registration

This randomized controlled clinical trial is registered at the Dutch trial register ( under NTR4395.


Anterior cruciate ligament reconstruction Hughston Clinic Knee score Limb symmetry index Maximal voluntary force Resistance training 



The authors thank BSc. A. Doornbos, BSc. A. Elsinghorst, BSc. K. Koorenhof, and BSc. L. Winkelhorst for their assistance with the data collection, MSc. E. Nieman and MSc. I. Brookman for performing the pilot study, Dr. R. Stewart for his assistance with the statistical analysis, and Medisch Centrum Zuid-Flytta for providing the research facilities.


This work was supported by start-up fund 653013 from the University Medical Center Groningen, Groningen, The Netherlands.

Compliance with ethical standards

Conflict of interest

The authors report that no conflicts of interest have occurred that are associated with the current study.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

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Supplementary material 1 (JPG 299 KB)
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Supplementary material 2 (DOCX 22 KB)
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Supplementary material 3 (DOCX 22 KB)
167_2018_5116_MOESM4_ESM.docx (23 kb)
Supplementary material 4 (DOCX 23 KB)


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Tjerk Zult
    • 1
    • 2
    Email author
  • Alli Gokeler
    • 1
  • Jos J. A. M. van Raay
    • 3
  • Reinoud W. Brouwer
    • 3
  • Inge Zijdewind
    • 4
  • Jonathan P. Farthing
    • 5
  • Tibor Hortobágyi
    • 1
  1. 1.Center for Human Movement SciencesUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
  2. 2.Vision and Eye Research Unit, School of MedicineAnglia Ruskin UniversityCambridgeUK
  3. 3.Department of Orthopedic SurgeryMartini HospitalGroningenThe Netherlands
  4. 4.Department of NeuroscienceUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
  5. 5.College of KinesiologyUniversity of SaskatchewanSaskatoonCanada

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