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Measurement properties for muscle strength tests following anterior cruciate ligament and/or meniscus injury: What tests to use and where do we need to go? A systematic review with meta-analyses for the OPTIKNEE consensus
  1. Anouk P Urhausen1,
  2. Bjørnar Berg2,3,
  3. Britt Elin Øiestad3,4,
  4. Jackie L Whittaker5,6,
  5. Adam G Culvenor7,
  6. Kay M Crossley7,
  7. Carsten B Juhl8,9,
  8. May Arna Risberg1,2
  1. 1 Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
  2. 2 Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
  3. 3 Centre for Intelligent Musculoskeletal Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
  4. 4 Department of Rehabilitation Science and Health Technology, Oslo Metropolitan University, Oslo, Norway
  5. 5 Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  6. 6 Arthritis Research Canada, Vancouver, British Columbia, Canada
  7. 7 La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Victoria, Australia
  8. 8 Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte, Copenhagen, Denmark
  9. 9 Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
  1. Correspondence to Anouk P Urhausen, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo 0806, Norway; anouku{at}


Objectives Critically appraise and summarise the measurement properties of knee muscle strength tests after anterior cruciate ligament (ACL) and/or meniscus injury using the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist.

Design Systematic review with meta-analyses. The modified Grading of Recommendations Assessment, Development and Evaluation-guided assessment of evidence quality.

Data sources Medline, Embase, CINAHL and SPORTSDiscus searched from inception to 5 May 2022.

Eligibility criteria for selecting studies Studies evaluating knee extensor or flexor strength test reliability, measurement error, validity, responsiveness or interpretability in individuals with ACL and/or meniscus injuries with a mean injury age of ≤30 years.

Results Thirty-six studies were included involving 31 different muscle strength tests (mode and equipment) in individuals following an ACL injury and/or an isolated meniscus injury. Strength tests were assessed for reliability (n=8), measurement error (n=7), construct validity (n=27) and criterion validity (n=7). Isokinetic concentric extensor and flexor strength tests were the best rated with sufficient intrarater reliability (very low evidence quality) and construct validity (moderate evidence quality). Isotonic extensor and flexor strength tests showed sufficient criterion validity, while isometric extensor strength tests had insufficient construct and criterion validity (high evidence quality).

Conclusion Knee extensor and flexor strength tests of individuals with ACL and/or meniscus injury lack evidence supporting their measurement properties. There is an urgent need for high-quality studies on these measurement properties. Until then, isokinetic concentric strength tests are most recommended, with isotonic strength tests a good alternative.

  • anterior cruciate ligament
  • meniscus
  • knee
  • reliability
  • validity

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  • Twitter @AnoukUrhausen, @jwhittak_physio, @agculvenor

  • Contributors JLW, AGC, KMC, CBJ and MAR contributed to the conception of the study. APU, BB, BEØ and MAR designed the study. APU and BB screened studies for inclusion, performed the data extraction and risk of bias assessment. All authors assisted with the interpretation of data. APU was the principal writer of the manuscript. All authors critically provided edits of the manuscript and approved the final version.

  • Funding This systematic review is part of the OPTIKNEE consensus (, which has received funding from the Canadian Institutes of Health Research (OPTIKNEE principal investigator JLW #161821). APU and MAR are recipients of the National Institutes of Health grant R37HD37985. AGC is a recipient of a National Health and Medical Research Council (NHMRC) of Australia Investigator Grant (GNT2008523). The funders had no role in any part of the study or in any decision about publication.

  • Competing interests JLW and AGC are Associate Editors of the British Journal of Sports Medicine (BJSM). JLW is an Editor with the Journal of Orthopaedic and Sports Physical Therapy. KMC is a senior advisor of BJSM, project leader of the Good Life with Osteoarthritis from Denmark (GLA:D)—Australia a not-for profit initiative to implement clinical guidelines in primary care, and holds a research grant from Levin Health outside the submitted work. All other authors declare no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.