Open-access Relação flexo-extensora de joelho após a reconstrução do ligamento cruzado anterior

fm Fisioterapia em Movimento Fisioter. mov. 0103-5150 1980-5918 Pontifícia Universidade Católica do Paraná Introdução A incidência de lesões de joelho em adultos jovens é muito alta, sendo a ruptura do ligamento cruzado anterior (LCA) a mais frequente. A avaliação por Dinamometria Isocinética determina o padrão funcional de força e equilíbrio muscular. Objetivos Comparar a relação das variáveis isocinéticas torque e trabalho de flexores e extensores do joelho em adultos jovens após a reconstrução cirúrgica do ligamento cruzado anterior. Metodologia: Foram selecionados 33 prontuários arquivados pelo laboratório de Isocinética da Clínica de Fisioterapia da Pontifícia Universidade Católica do Paraná (PUCPR), de pacientes que realizaram a avaliação isocinética a pedido de fisioterapeutas e de médicos da cidade de Curitiba (PR). Os dados tabulados foram: relação flexora/extensora de pico de torque e trabalho em todos os membros lesionados e não-lesionados a uma velocidade angular de 60°/s. Os dados foram tratados pelo software de estatística LHstat. A estatística inferencial foi empregada para aplicar o teste de comparação entre médias (Teste t não pareado) com um intervalo de confiança de 95%. Resultados A média da relação flexo-extensora é menor no membro não envolvido tanto no pico de torque (relação pico de torque do membro não envolvido 56,1% e relação do pico de torque do membro envolvido 66,3%, apresentando diferença de 10,2%) quanto no trabalho (relação do trabalho no membro não envolvido 60,1% e relação do trabalho do membro envolvido 66,1% apresentando diferença de 6%). Conclusão A média encontrada da relação flexo-extensora foi adequada para ambos os membros e variáveis, no entanto os indivíduos apresentaram assimetrias musculares em maior número no membro envolvido do que no membro não envolvido. Introduction The incidence of knee injuries is very high in young adults and reaches approximately 70% in sports practice. Anterior cruciate ligament (ACL) disruption is the most frequent of these injuries and males are usually more affected by it. However, the incidence in females is increasing every year (1, 2, 3). The ACL is responsible for about 85% of the anterior stabilization of the knee joint. The signs and symptoms that indicate its rupture include: joint stroke, cracking, missteps, pain and difficulty in performing some daily life activities. Nevertheless, some individuals do not report symptoms and are classified as adapted to the injury. Surgery candidates usually present motor impairments and have the intention of returning to sport (4, 5). Among the surgical reconstruction procedures available, the most common grafts are derived from the patellar tendon, the tendon of the semitendinosus muscle, cadavers (allograft), or are synthetic grafts. Morbidity of the site the graft is acquired from, muscle weakness associated with initial injury and the surgical procedure itself are factors that may interfere with postoperative recovery (6, 7). In injured knees, the hamstrings act as ACL synergists and help reduce the incidence of new ligament injuries (8). Even if the knee presents stability and good range of motion, the ultimate goal of surgical reconstruction cannot be achieved without the recovery of muscle strength (8, 9). The interest in assessing muscle performance of the knee extensors and flexors is due to the fact that they are reference values for the isokinetic and functional recovery progression and the return to sports (10, 11). Isokinetic dynamometry is a reliable method of determining the functional pattern of muscle strength and balance. In this context, isokinetic variables such as peak torque, work, and power are important. The application of these variables in the balance relationship between flexors and extensors (FLEX/EXT) of the knee has been identified as an important tool to evaluate the functional ability of joints and to calculate indices of injury risk (12, 13). Thus, the aim of this study was to compare the isokinetic hamstring/quadriceps peak torque and work ratios. Materials and methods This is an applied study. We used a quantitative descriptive approach and the research design was ex-post facto and documental (14). Data collection was performed in August 2010. We collected data from October 2007 to June 2010, through the selection of 33 medical records archived by the Isokinetic laboratory of the Physiotherapy Clinic of the Catholic University of Paraná (PUCPR) which met inclusion and exclusion criteria. Inclusion criteria were: male gender; age between 20 and 30 years; postoperative (PO) ACL reconstruction with semitendinosus graft and Isokinetic assessment performed 4-8 months after surgery. Exclusion criteria were: a bilateral knee injury; musculoskeletal and joint disorders of the knees; systemic and neurological diseases. All of the selected records belonged to patients who had undergone isokinetic assessment at the request of a physiotherapist or physician in the city of Curitiba. There was, therefore, no prior contact with any recovery stage. Individuals undergoing the isokinetic testing were previously assessed through the use of a physical therapy record, on which personal data, height (estimated by use of stadiometer), body weight (assessed by scale), clinical diagnosis, and other data were recorded. After this first contact was made, patients performed a 5-minute warm-up on a cycle ergometer with 5Kpm load. This was followed by the isokinetic assessment, which was performed by using the Cybex isokinetic dynamometer (model Norm 700). All assessments were performed by only one experienced reviewer. The non-involved member was tested first. The patient was sitting down when the measurement was taken and all parameters recommended by the manufacturer were followed: slightly reclined trunk; properly stabilized trunk, thigh and legs; axis of rotation of the lever arm was properly aligned to the lateral femoral condyle. Range of motion in the knee was 100° of flexion to 0° of extension. The procedure was fully explained to the patient, who performed a specific warming-up, two submaximal contractions and one maximum contraction for familiarization and recruitment of motor units. An angular velocity of 60°/s was measured in concentric mode and the patient performed three maximum repetitions. The tabulated data were: Hamstring/Quadriceps peak torque and work ratios in all injured and uninjured limbs at an angular velocity of 60°/s. The postoperative time period and the side involved were also assessed. The Body Mass Index (BMI) of the entire sample was calculated as body weight divided by height squared (kg/m2). Data were then processed by the statistical software LHstat and presented though descriptive statistics, graphs and tables. The inferential statistics was used in order to apply the comparison test between means (unpaired t-test) with a confidence interval of 95%. Peak torque ratios between 49.9% and 69.9% were considered to be normal or appropriate (both for peak torque and work). Values above 69.9% and below 49.9% were considered to be abnormal or inadequate. Results The average body weight was 78.6 ± 7.58 kg (minimum of 60 kg and maximum of 90 kg). The average height was 1.78 ± 0.06 m (minimum of 1.63 m and maximum of 1.91 m). The BMI average was 24.76 ± 2.20 kg/m2 (minimum of 20.76 kg/m2 and maximum of 29.41 kg/m2). We found that 22 subjects had a healthy BMI (normal range between 18.5 and 24.9 kg/m2) and 11 subjects were above the recommended weight (25 to 29.9 kg/m2). Regarding the anatomic distribution of the injury, among the 33 cases selected, 15 cases (45.45%) had injured the nondominant limb and 18 (54.55%) had injured the dominant limb. Most of the subjects (60.61%) were evaluated after 4-5 months (60.61%) and 39.39% were assessed after 6-8. Table 1 shows the descriptive statistical findings of the following variables: hamstring/quadriceps peak torque ratio in the non-involved limb (PTRNI); hamstring/quadriceps peak torque ratio in the involved limb (PTRI); quadriceps-to-hamstring work ratio in the non-involved limb (WRNI) and quadriceps-to-hamstring work ratio in the involved limb (WRI). Table 1 Comparison of the hamstring/quadriceps peak torque ratio: descriptive statistical findings Variable Peak torque   Work Non-involved limb Involved limb   Non-involved limb Involved limb Minimum 41.8% 36.5%   46.3% 36.9% Maximum 70.4% 129.5%   75.3% 127.9% Average 56.1 ± 7.4% 66.3 ± 18%   60.1 ± 7.4% 66.1 ± 17.1% Source: Research data. The PTRNI obtained approximately 75.8% of the sample with values between 49.9% to 69.9%. The PTRI obtained approximately 60.6% of the sample with values between 49.9% to 69.9%. The average PTRNI was 56.1%, and the average PTRI was 66.3%. Thus, the difference between members was 10.2%, considered statistically significant (p < 0.05). The average comparison test was performed with paired data and a normal distribution of sample means at a significance level of 5%. Student's t value was < 1% error. Thus, PTRI is higher than PTRNI. The WRNI obtained approximately 81.8%, with values between 49.9% and 69.9%. However, the WRI obtained about 69.7% of the sample, with values between 49.9% and 69.9%. The average WRNI was 60.1%, and the average WRI was 66.1%. Thus, the difference between limbs was 6%, considered statistically significant (p < 0.05). The average comparison test was also performed with paired data and a normal distribution of sample means at a significance level of 5%. Student's t value was < 2% error. Thus, WRI is higher than WRNI Tests of normality and homoscedasticity were performed for the analysis of the variables (PTRNI, PTRI, WRI and WRNI). The Shapiro-Wilk normality test accepts the hypothesis of normal distribution. A significance level of 5% or 0.05 was used. If the p-value is below 0.05, the hypothesis of normality for the variable analyzed is rejected. The PTRNI and WRNI variables had p-values > 0.05; which denotes a normal distribution. The PTRI and WRI variables, on the other hand, had p-values < 0.05; which denotes an abnormal distribution. This change is due to the high value of standard deviation associated with these variables, which are related to the injured knee. The homoscedasticity test supports the hypothesis of uniform variance of distribution is also based on the p-value and has a significance level of 0.05. All of the analyzed variables analyzed showed values > 0.05; which indicates the homogeneity of the sample. With a sample of 33 individuals, it is not necessary that its variables follow the normal distribution, because, regardless of the distribution of these variables, their average will be close enough to the normal distribution in order to allow for the use of the t-test (15). Table 2 shows the distribution of normal and abnormal cases among the variables, both in absolute value and in percentage. We found a greater hamstrings weakness values in the non-involved lower limb for the peak torque variable. However, for all other variables, quadriceps weakness values were higher, even though the sample was constituted by subjects who had undergone ACL reconstruction using a graft of the semitendinosus muscle. Table 2 Distribution of cases among the variables (absolute value and percentage) Variable Normal*   Abnormal**       (Quantity)   Higher Lower   Total % PTRNI 25 75.8%   1 7   8 24.2% PTRI 20 60.6%   9 4   13 39.4% WRNI 27 81.8%   4 2   6 18.2% WRI 23 69.7%   8 2   10 30.3% Note: PTRNI = hamstring/quadriceps peak torque ratio of the non-involved limb; PTRI = hamstring/quadriceps peak torque ratio of the involved limb; WRNI = quadriceps-to-hamstring work ratio of the non-involved limb; WRI = quadriceps-to-hamstring work ratio of the involved limb; *Normal = PTRNI and PTRI are between 49.9 and 69.9%; **Abnormal = Higher than 69.9% and Lower than 49.9%. Source: Research data. Table 3 shows the distribution of cases of quadriceps-to-hamstring peak torque and work ratios, according to postoperative months and in absolute number and percentage. Table 3 Distribution of cases among the variables (absolute value and percentage) Peak torque   Work Time (months) Normal *n (%) Abnormal **   Time (months) Normal *n (%) Abnormal ** I NI None *** %   I NI None *** % 4 5 (15.2%) 5 1 2 24.2   4 8 (24.2%) 2 2 1 15.2 5 3 (09.1%) 2 1 1 12.1   5 5 (15.2%) 2 0 0 06.0 6 à 8 6 (18.2%) 4 2 1 21.2   6 à 8 7 (21.2%) 4 1 1 18.2 Total 14 (42.5%) 11 4 4 57.5   Total 20 (60.6%) 8 3 2 39.4 Note: I = involved limb; NI = non-involved limb; *Normal = NI and I are between 49.9 and 69.9%; **Abnormal = NI and I are lower than 49.9% and/or higher than 69.9%; *** None = none of the lower limbs has any values between 49.9 and 69.9%. Source: Research data. Regarding the peak torque, we observed that 14 subjects had muscle balance and 19 subjects still presented alterations in this aspect, both bilaterally and unilaterally. With regards to work, 20 subjects showed balance, while 13 subjects showed alterations from normality. According to the data from Table 3, there are more individuals with muscle dysfunction or deficit in the involved limb than in the non-involved limb, independent of the month considered. However, the study also found changes in muscle strength in both limbs. Data crossing of BMI data with standard values for the agonist-antagonist ratio (49.9% to 69.9%) resulted in the formation of two groups: normal BMI and overweight BMI. 15.2% of the sample had normal BMI and balance of the agonist-antagonist ratio, 27.3% of the sample showed weakness of the extensor muscles, 21.2% showed weakness of the flexor muscles, and only 3% showed weakness of both agonists and antagonists. 21.2% of the sample had overweight BMI and shoed balance of agonist-antagonist ratio, 9.1% showed weakness of extensor muscles and 3% showed weakness of the hamstrings. Discussion The isokinetic assessment has been used in recent decades as a method to determine the functional pattern of muscular strength and balance through the analysis of the following variables: peak torque and agonist-antagonist balance ratio. The angular velocity of 60°/s is widely used to evaluate the maximum joint moment given in torque, basically for two reasons: the first is that, the smaller the angular velocity the larger the torque; the second is because at this speed there will hardly be fatigue, obviously respecting the maximum number of 3 repetitions. In the present study, we used the flexor/extensor (FLX/EXT) ratio as an assessment parameter, because it is an indicator of normality with regard to the balance between the function of the extensors and flexors of the knee. There is a 50-70% oscillation in the flexor/extensor ratio of the healthy knee joint (12, 16, 17, 18, 19). Normally, muscle imbalances in the knee are assessed using the conventional ratio (concentric hamstrings/concentric quadriceps). Values between 0.5 and 0.7 are considered normal. FLX/EXT ratio around 60%, at an angular velocity of 60°/s , had good acceptability; there is, however, no consensus on the desired normative value. Nevertheless, the use of the conventional ratio alone has limitations since it represents a situation that is absent during the execution of functional movements. Therefore, the functional ratio (eccentric flexor peak torque/ extensor concentric peak torque ) is currently used for this evaluation. Changes in this ratio predispose to injury in the knee joint and strains in the hamstring muscles (17, 19, 20, 21, 22, 23). In the present study we could confirm average values of 50 to 70% for the agonist-antagonist ratio within 4 to 8 months of postoperative reavaluation in the absolute majority of the sample. Quadriceps muscle atrophy, instability and pain are clinical complaints that may be explained by deficits in muscle performance after the recovery process (20, 24, 25). The loss of muscle strength is associated with proprioceptive loss, thus, one should be cautious when using the non-injured side as a normal parameter for the injured side, because the injured side can influence the contralateral side (4, 17). Studies in subjects with ACL disruption show that return to function at pre-injury level is dependent on the knee extensor strength and that return to a functional level is positively correlated with muscle strength assessments. The FLX/EXT ratio in healthy individuals reaches between 50% and 60% and the increase in FLX/EXT is probably due to a extensor muscle strength deficit (10). Loss of muscle strength in the postoperative ACL reconstruction population has been frequently documented because it is a limiting factor for the return to physical activities. Isokinetic assessment allows more precise measurements and has a major impact on clinical decision making. Among the tests and equipments developed for evaluation of muscle performance of the knee extensors and flexors, computerized isokinetic dynamometers are considered gold standard. Values obtained in the isokinetic test are, in theory, more realistic in relation to maximum muscle functional capacity. Some studies have indicated higher knee extensor peak torque values for the non-involved limb than for the involved limb. They allege that the recovery of the extensor mechanism is slow and difficult. After ACL rupture, it is possible to identify a greater weakness of quadriceps than hamstrings (26). In another study, it was shown that, even after five years of ACL reconstruction (26), during which time the recovery of muscle function is expected, physical evaluation revealed a deficit in muscle strength (11, 26, 27, 28, 29, 30, 31). In a survey, eleven amateur-level athletes (29) were evaluated months after ACL reconstruction using patellar tendon autogtraft. Its results show that the FLX/EXT ratio is lower on the involved side. On the other hand, the assessment of twenty-eight athletes who had ACL laxity or not (31), could not detect significant differences in FLX/EXT ratios between the two groups. This evidences that ACL laxity does not affect knee joint muscle balance. Another study evaluated 6 patients in the preoperative and postoperative period on two occasions (31): after 4 months and one year. An imbalance in the FLX/EXT relationship after ACL reconstruction was found, especially in the period of 4 months after surgery (21, 29, 31, 32). Our study found a higher FLX/EXT ratio on the injured limb, when compared to the non-injured side. This suggests a deficit of the extensor muscles. Our results show a higher FLX/EXT ratio on the reconstructed knee both in the peak torque (10 % deficit between limbs) and in work (6.3 % deficit between limbs). A muscle-ligament reflex prevents excessive Anterior Tibial Translation (ATT). It promotes the inhibition of the quadriceps and the activation of the hamstring, which act as a dynamic agonist of the ACL in injured individuals (27). However, there is a significant difference in the agonist/antagonist relation, due to the quadriceps deficit and a little loss of strength of hamstrings, promoting an imbalance in the relationship. During the postoperative recovery the readjustment of the FLX/EXT relationship is sought. However, an excessive development of quadriceps strength contributes to a decreased antagonist coactivation of the hamstrings and favors ligament rupture, due to the decrease in the stabilizing forces of this joint (8, 18, 22, 27, 32, 33). Muscle imbalances detected by the FLX/EXT ratio are associated with a higher incidence of injury in athletes. The current literature shows evidence that the muscle coactivation that takes place in the knee would serve to protect and stabilize the joint during powerful muscle contractions. Moreover, it would be responsible for distributing pressure across the joint and minimizing fatigue and joint damage (24, 34). Among soccer and futsal players (35), the FLX/EXT ratio at 60°/s had an average of 54.7%. The authors suggested that the ideal ratio for football players was 65%. Other studies (36), found a FLX/EXT of 60.7% (at the same speed) in men and an average of 48 and 51% in young volleyball players (37). Thus, in the present study, the involved limb presented higher averages of FLX/EXT peak torque and work ratios. Even though within the normal range (49.9% to 69.9%), they were closer to the superior boundary value, which suggests a tendency for extensor muscle strength deficiency. It can be observed, taking the value of normality as parameter, that there was a decrease of approximately 15% of the total sample for the peak torque ratio and 12% of the total sample for the work ratio, when the non-injured limb was compared with the injured. The lowest absolute percentage of the sample found in the involved limbs may suggest the process of functional recovery, which is still in continuity. This correlation further demonstrates the difficulty in achieving muscular balance during post-surgical recovery process, given the fact that not even the healthy limb reached 100% of normality. In sedentary people, muscle imbalances values lower than 10% are considered normal and acceptable. However, in athletes, imbalance values superior to 5% may, sometimes, already be important, because their muscles must be well conditioned for maximum performance during sports activity (38). The imbalance between the strength of the quadriceps and hamstring muscles suggests not to exceed the potential strength of the quadriceps more than 10% in relation to the hamstring muscles, in order to protect the joints and muscles. It is stated that a reduction of 50-60 % of the strength of the hamstrings to the quadriceps predisposes to injury. A careless strength training of the hamstring muscles may reduce coactivation of antagonists in response to the superiority of quadriceps strength (38). We found in this study, a bilateral difference of 10.2 % for the FLX/EXT peak torque ratio and 6 % for the work ratio, which brings a concern about the imbalance found, given the fact that, in a sample of physically active people, such indices may be interpreted as a risk of injury. Conclusion Muscle balance was presented by some subjects, but not by the whole sample. We found lower normal FLX/EXT peak torque ratios unilaterally than bilaterally. With regard to the work, the study revealed that most of the sample presented muscle balance and a smaller part presented asymmetries. Regarding the measuring variables (peak torque and work), individuals presented a great number of muscle deficits in the involved limb than in the non-involved limb. Therefore, we suggest the need to promote greater attention to the functional recovery of muscle strength of the limb involved by the lesion, yet without forgetting the importance of maintaining muscle strength and balance of the contralateral limb, both in bilateral balance and FLX/EXT ratio. References 1 . Kisner C, Colby LA. Exercícios terapêuticos: fundamentos e técnicas. 4. ed. São Paulo: Manole; 2005. Kisner C Colby LA Exercícios terapêuticos: fundamentos e técnicas 4 São Paulo Manole 2005 2 . Tria AJ. Lesões ligamentares do joelho: anatomia, diagnóstico, tratamento e resultados. Rio de Janeiro: Revinter; 2002. Tria AJ Lesões ligamentares do joelho: anatomia, diagnóstico, tratamento e resultados Rio de Janeiro Revinter 2002 3 . Cohen M. Tratado de Ortopedia. São Paulo: Roca; 2007. Cohen M Tratado de Ortopedia São Paulo Roca 2007 4 . Fatarelli IFC, Almeida GL, Nascimento BG. Lesão e reconstrução do LCA: uma revisão biomecânica e do controle motor. Rev Bras Fisioter. 2004;8(3):197-206. Fatarelli IFC Almeida GL Nascimento BG Lesão e reconstrução do LCA: uma revisão biomecânica e do controle motor Rev Bras Fisioter 2004 8 3 197 206 5 . Silva R, Matos MA, Silva DJA, Abreu MS. Associação entre tempo de rupturas do ligamento cruzado anterior e frequência de outras lesões articulares do joelho. Rev Bras Ortop. 2006;41(7):268-71. Silva R Matos MA Silva DJA Abreu MS Associação entre tempo de rupturas do ligamento cruzado anterior e frequência de outras lesões articulares do joelho Rev Bras Ortop 2006 41 7 268 271 6 . Eriksson K, Hamberg P, Jansson E, Larsson H, Shalabi A, Wredmark T. Semitendinosus muscle in anterior cruciate ligament surgery: morphology and function. Arthroscopy. 2001;17(8):808-17. Eriksson K Hamberg P Jansson E Larsson H Shalabi A Wredmark T Semitendinosus muscle in anterior cruciate ligament surgery: morphology and function Arthroscopy 2001 17 8 808 817 7 . Vasconcelos RA, Bevilaqua-Grossi D, Shimano AC, Paccola CJ, Salvini TF, Prado CL, et al. Análise da correlação entre pico de torque, desempenho funcional e frouxidão ligamentar em indivíduos normais e com reconstrução do ligamento cruzado anterior. Rev Bras Ortop. 2009;44(2):134-42. Vasconcelos RA Bevilaqua-Grossi D Shimano AC Paccola CJ Salvini TF Prado CL et al Análise da correlação entre pico de torque, desempenho funcional e frouxidão ligamentar em indivíduos normais e com reconstrução do ligamento cruzado anterior Rev Bras Ortop 2009 44 2 134 142 8 . Rosene JM, Fogarty TD, Mahaffey BL. Isokinetic hamstrings: quadriceps ratios in intercollegiate athletes. J Athl Train. 2001;36(4):378-83. Rosene JM Fogarty TD Mahaffey BL Isokinetic hamstrings: quadriceps ratios in intercollegiate athletes J Athl Train 2001 36 4 378 383 9 . Kobayashi A, Higuchi H, Terauchi M, Kobayashi F, Kimura M, Takagishi K. Muscle performance after anterior cruciate ligament reconstruction. Int Orthop. 2004;28(1):48-51. Kobayashi A Higuchi H Terauchi M Kobayashi F Kimura M Takagishi K Muscle performance after anterior cruciate ligament reconstruction Int Orthop 2004 28 1 48 51 10 . Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Hamstring and quadriceps strength balance in normal and hamstring anterior cruciate ligament-reconstructed subjects. Clin J Sport Med. 2004;14(5):274-80. Hiemstra LA Webber S MacDonald PB Kriellaars DJ Hamstring and quadriceps strength balance in normal and hamstring anterior cruciate ligament-reconstructed subjects Clin J Sport Med 2004 14 5 274 280 11 . Vasconcelos RA, Bevilaqua-Grossi D, Shimano AC, Paccola CJ, Salvini TF, Prado CL, et al. Confiabilidade e validade de um dinamômetro isométrico modificado na avaliação do desempenho muscular em indivíduos com reconstrução do ligamento cruzado anterior. Rev Bras Ortop. 2009;44(3):214-24. Vasconcelos RA Bevilaqua-Grossi D Shimano AC Paccola CJ Salvini TF Prado CL et al Confiabilidade e validade de um dinamômetro isométrico modificado na avaliação do desempenho muscular em indivíduos com reconstrução do ligamento cruzado anterior Rev Bras Ortop 2009 44 3 214 224 12 . Machado SM, Souza RA, Simão AP, Jerônimo DP, Silva NS, Osorio RAL, et al. Estudo comparativo de variáveis isocinéticas do joelho em atletas de taekwondo e kickboxing. Fit Perf J. 2009;8(6):407-11. Machado SM Souza RA Simão AP Jerônimo DP Silva NS Osorio RAL et al Estudo comparativo de variáveis isocinéticas do joelho em atletas de taekwondo e kickboxing Fit Perf J 2009 8 6 407 411 13 . Goulart LF, Dias RMR, Altimari LR. Variação do equilíbrio muscular durante uma temporada em jogadores de futebol categoria sub-20. Rev Bras Med Esporte. 2008;14(1):17-21. Goulart LF Dias RMR Altimari LR Variação do equilíbrio muscular durante uma temporada em jogadores de futebol categoria sub-20 Rev Bras Med Esporte 2008 14 1 17 21 14 . Gil AC. Como elaborar projetos de pesquisa.4. ed. São Paulo: Atlas; 2002. Gil AC Como elaborar projetos de pesquisa 4 São Paulo Atlas 2002 15 . Loesch C. Probabilidade e estatística. Rio de Janeiro: LTC; 2012. Loesch C Probabilidade e estatística Rio de Janeiro LTC 2012 16 . Bowerman SJ, Smith DR, Carlson M, King GA. A comparison of factors influencing ACL injury in male and female athletes and non-athletes. Phys Ther Sport. 2006;7(3):144-52. Bowerman SJ Smith DR Carlson M King GA A comparison of factors influencing ACL injury in male and female athletes and non-athletes Phys Ther Sport 2006 7 3 144 152 17 . Kong PW, Burns SF. Bilateral difference in hamstrings to quadriceps ratio in healthy males and females. Phys Ther Sport. 2010;11(1):12-7. Kong PW Burns SF Bilateral difference in hamstrings to quadriceps ratio in healthy males and females Phys Ther Sport 2010 11 1 12 17 18 . Holcomb WR, Rubley MD, Lee HJ, Guadagnoli MA. Effect of hamstring-emphasized resistance training on hamstring: quadriceps strength ratios. J Strength Cond Res. 2007;21(1):41-7. Holcomb WR Rubley MD Lee HJ Guadagnoli MA Effect of hamstring-emphasized resistance training on hamstring: quadriceps strength ratios J Strength Cond Res 2007 21 1 41 47 19 . Terreri ASAP, Greve JMD, Amatuzzi MM. Avaliação isocinética no joelho do atleta. Revista Brasileira de Medicina do Esporte. 2001;7(5):170-4. Terreri ASAP Greve JMD Amatuzzi MM Avaliação isocinética no joelho do atleta Revista Brasileira de Medicina do Esporte 2001 7 5 170 174 20 . Rezende GF, Pereira LB, Bittencourt L. Dados normativos de força concêntrica, excêntrica, relação agonista/antagonista e relação funcional do joelho em atletas de futebol. Anais do 1. Congresso Brasileiro de Fisioterapia Esportiva, 2004, Guarujá. São Paulo: Sociedade Nacional de Fisioterapia Esportiva; 2004. Rezende GF Pereira LB Bittencourt L Dados normativos de força concêntrica, excêntrica, relação agonista/antagonista e relação funcional do joelho em atletas de futebol Anais do 1. Congresso Brasileiro de Fisioterapia Esportiva 2004 Guarujá São Paulo Sociedade Nacional de Fisioterapia Esportiva 2004 21 . Fonseca ST, Ocarino JM, Silva PLP, Bricio RS, Costa CA, Wanner LL. Caracterização da performance muscular em atletas profissionais de futebol. Rev Bras Med Esporte. 2007;13(3):143-7. Fonseca ST Ocarino JM Silva PLP Bricio RS Costa CA Wanner LL Caracterização da performance muscular em atletas profissionais de futebol Rev Bras Med Esporte 2007 13 3 143 147 22 . Coombs R, Garbutt G. Developments in the use of the hamstring: quadriceps ratio for the assessment of muscle balance. J Sports Sci Med. 2002;1(3):56-62. Coombs R Garbutt G Developments in the use of the hamstring: quadriceps ratio for the assessment of muscle balance J Sports Sci Med 2002 1 3 56 62 23 . Weber FS, Silva BGC, Radaelli R, Paiva C, Pinto RS. Avaliação isocinética em jogadores de futebol profissional e comparação do desempenho entre as diferentes posições ocupadas no campo. Rev Bras Med Esporte. 2010;16(4):264-8. Weber FS Silva BGC Radaelli R Paiva C Pinto RS Avaliação isocinética em jogadores de futebol profissional e comparação do desempenho entre as diferentes posições ocupadas no campo Rev Bras Med Esporte 2010 16 4 264 268 24 . Pássaro AC, Marques AP, Sacco ICN, Amadio AC, Bacarin TA. Mecanismos de ativação agonista e antagonista no joelho de indivíduos com reconstrução de ligamento cruzado anterior: estudo cinético e eletromiográfico. Acta Ortop Bras. 2008;16(2):117-21. Pássaro AC Marques AP Sacco ICN Amadio AC Bacarin TA Mecanismos de ativação agonista e antagonista no joelho de indivíduos com reconstrução de ligamento cruzado anterior: estudo cinético e eletromiográfico Acta Ortop Bras 2008 16 2 117 121 25 . Dvir Z. Isocinética: avaliações musculares, interpretações e aplicações clínicas. São Paulo: Manole; 2002. Dvir Z Isocinética: avaliações musculares, interpretações e aplicações clínicas São Paulo Manole 2002 26 . Lautamies R, Harilainen A, Kettunen J, Sandelin J, Kujala UM. Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2008;16(11):1009-16. Lautamies R Harilainen A Kettunen J Sandelin J Kujala UM Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts Knee Surg Sports Traumatol Arthrosc 2008 16 11 1009 1016 27 . Vasconcelos RA, Arakaki JC, Simão AP, Oliveira AS, Paccola CJ, Bevilaqua-Grossi D. Análise da translação anterior da tíbia, pico de torque e atividade eletromiográfica do quadríceps e isquiotibiais em indivíduos com lesão do ligamento cruzado anterior em cadeia cinética aberta. Acta Ortop Bras. 2007;15(1):14-8. Vasconcelos RA Arakaki JC Simão AP Oliveira AS Paccola CJ Bevilaqua-Grossi D Análise da translação anterior da tíbia, pico de torque e atividade eletromiográfica do quadríceps e isquiotibiais em indivíduos com lesão do ligamento cruzado anterior em cadeia cinética aberta Acta Ortop Bras 2007 15 1 14 18 28 . Aquino CF, Vaz DV, Brício RS, Silva PLP, Ocarino JM, Fonseca ST. A utilização da dinamometria isocinética nas ciências do esporte e reabilitação. R Bras Ci e Mov. 2007;15(1):93-100. Aquino CF Vaz DV Brício RS Silva PLP Ocarino JM Fonseca ST A utilização da dinamometria isocinética nas ciências do esporte e reabilitação R Bras Ci e Mov 2007 15 1 93 100 29 . Jamshidi AA, Olyaeia GR, Heydarian K, Talebian S. Isokinetic and functional parameters in patients following reconstruction of the anterior cruciate ligament. IES. 2005;13(4):267-72. Jamshidi AA Olyaeia GR Heydarian K Talebian S Isokinetic and functional parameters in patients following reconstruction of the anterior cruciate ligament IES 2005 13 4 267 272 30 . Pincivero DM, Heller BM, Hou SI. The effects of ACL injury on quadriceps and hamstring torque, work and power. J Sports Sci. 2002;20(9):689-96. Pincivero DM Heller BM Hou SI The effects of ACL injury on quadriceps and hamstring torque, work and power J Sports Sci 2002 20 9 689 696 31 . Portes EM, Portes LA, Botelho VG, Pinto SS. Isokinetic torque peak and hamstrings/quadriceps ratios in endurance athletes with anterior cruciate ligament laxity. Clinics. 2007;62(2):127-32. Portes EM Portes LA Botelho VG Pinto SS Isokinetic torque peak and hamstrings/quadriceps ratios in endurance athletes with anterior cruciate ligament laxity Clinics 2007 62 2 127 132 32 . Traete RF, Pinto KNZ, Mattiello-Rosa SM. Relationship between chondral lesion and peak torque following anterior cruciate ligament reconstruction: case study. Rev Bras Fisioter. 2007;11(3):239-43. Traete RF Pinto KNZ Mattiello-Rosa SM Relationship between chondral lesion and peak torque following anterior cruciate ligament reconstruction: case study Rev Bras Fisioter 2007 11 3 239 243 33 . Ageberg E, Roos HP, Silbernagel KG, Thomeé R, Roos EM. Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery. Knee Surg Sports Traumatol Arthrosc. 2009;17(2):162-9. Ageberg E Roos HP Silbernagel KG Thomeé R Roos EM Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery Knee Surg Sports Traumatol Arthrosc 2009 17 2 162 169 34 . Iga J, George K, Lees A, Reilly T. Cross-sectional investigation of indices of isokinetic leg strength in youth soccer players and untrained individuals. Scand J Med Sci Sports. 2009;19(5):714-9. Iga J George K Lees A Reilly T Cross-sectional investigation of indices of isokinetic leg strength in youth soccer players and untrained individuals Scand J Med Sci Sports 2009 19 5 714 719 35 . Alexandre PF, Lacerda RC, Deus LA, Melo FT, Alves MGS. Análise comparativa do desempenho muscular isocinético entre jogadores de futebol e futsal. Educ Fís Rev. 2009;3(2):1-12. Alexandre PF Lacerda RC Deus LA Melo FT Alves MGS Análise comparativa do desempenho muscular isocinético entre jogadores de futebol e futsal Educ Fís Rev 2009 3 2 1 12 36 . Hewett TE, Myer GD, Zazulak BT. Hamstrings to quadriceps peak torque ratios diverge between sexes with increasing isokinetic angular velocity. J Sci Med Sport. 2008;11(5):452-9. Hewett TE Myer GD Zazulak BT Hamstrings to quadriceps peak torque ratios diverge between sexes with increasing isokinetic angular velocity J Sci Med Sport 2008 11 5 452 459 37 . Bittencourt NFN, Amaral GM, Anjos MTS, D’Alessandro RD, Silva AA, Fonseca ST. Isokinetic muscle evaluation of the knee joint in athletes of the under-19 and under-21 male Brazilian national volleyball team. Rev Bras Med Esporte. 2005;11(6):302-6. Bittencourt NFN Amaral GM Anjos MTS D’Alessandro RD Silva AA Fonseca ST Isokinetic muscle evaluation of the knee joint in athletes of the under-19 and under-21 male Brazilian national volleyball team Rev Bras Med Esporte 2005 11 6 302 306 38 . Assis MMV, Gomes MI, Carvalho EMS. Avaliação isocinética de quadríceps e ísquios-tibiais nos atletas de jiu-jitsu. Rev Bras Promoç Saúde. 2005;18(2):85-9. Assis MMV Gomes MI Carvalho EMS Avaliação isocinética de quadríceps e ísquios-tibiais nos atletas de jiu-jitsu Rev Bras Promoç Saúde 2005 18 2 85 89
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