Correlation between post-operative knee swelling and pain, maximal voluntary muscle contraction, and function following ACL reconstruction: a longitudinal study

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This study aimed to explore the association of PKOS with pain, ROM, maximum voluntary contraction (MVC), and functional outcome after ACLR. Methods Thirty-two subjects undergoing ACLR were recruited for this study. PKOS, pain, ROM, and MVC were measured on days 0, 1, 2, 3, 2nd week, and 6th week, while functional outcome was assessed using the Lower Extremity Functional Scale (LEFS) after 2 weeks and 6 weeks. Girth measurement was taken to assess swelling, pain was assessed using a visual analog scale (VAS), and MVC was analyzed using surface electromyography®. Results Mean values for PKOS, VAS, ROM, MVC, and functional outcome showed overall improvement from day 0 to week 6, except for MVC values, which exhibited fluctuations from day 2 to day 3. However, no significant association (p > 0.05) was found between PKOS and pain, ROM, MVC, and functional outcome. Conclusion While PKOS improved along with other variables over the recovery period, it exhibited no significant correlation with pain, ROM, strength, or functional outcome post-ACLR, warranting further investigation. Registration: Clinical Trial Registry (CTRI/2022/03/041101). " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-818/v1", "name": "Correlation between post-operative knee swelling and pain, maximal..." } } ] } Home Browse Correlation between post-operative knee swelling and pain, maximal... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Shenoy S, Prabhakar AJ, Eapen C et al. Correlation between post-operative knee swelling and pain, maximal voluntary muscle contraction, and function following ACL reconstruction: a longitudinal study [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :818 ( https://doi.org/10.12688/f1000research.166364.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Correlation between post-operative knee swelling and pain, maximal voluntary muscle contraction, and function following ACL reconstruction: a longitudinal study [version 1; peer review: awaiting peer review] Shwetha Shenoy 1 , Ashish John Prabhakar https://orcid.org/0000-0001-5801-6185 1 , Charu Eapen 1 , [...] Dias Tina Thomas https://orcid.org/0000-0001-9297-2269 1 , Vijayakumar Palaniswamy https://orcid.org/0009-0002-0628-5505 2 , Molly Cynthia Dsouza 1 , Yogeesh Dattakumar Kamat 3 Shwetha Shenoy 1 , Ashish John Prabhakar https://orcid.org/0000-0001-5801-6185 1 , [...] Charu Eapen 1 , Dias Tina Thomas https://orcid.org/0000-0001-9297-2269 1 , Vijayakumar Palaniswamy https://orcid.org/0009-0002-0628-5505 2 , Molly Cynthia Dsouza 1 , Yogeesh Dattakumar Kamat 3 PUBLISHED 26 Aug 2025 Author details Author details 1 Department of Physiotherapy, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India 2 Institute of Physiotherapy Pandeshwar, Srinivas University City campus, Mangaluru, 575001, Karnataka, India 3 Department of Orthopedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India Shwetha Shenoy Roles: Investigation, Project Administration, Writing – Original Draft Preparation Ashish John Prabhakar Roles: Conceptualization, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Charu Eapen Roles: Conceptualization, Supervision, Writing – Review & Editing Dias Tina Thomas Roles: Writing – Review & Editing Vijayakumar Palaniswamy Roles: Writing – Review & Editing Molly Cynthia Dsouza Roles: Supervision, Writing – Review & Editing Yogeesh Dattakumar Kamat Roles: Methodology, Project Administration, Writing – Original Draft Preparation OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Manipal Academy of Higher Education gateway. Abstract Background Postoperative knee swelling (PKOS) following anterior cruciate ligament reconstruction (ACLR) is known to contribute to deficits such as pain, swelling, reduced range of motion (ROM), and strength, impeding quadriceps activation, inducing arthrogenic muscle inhibition (AMI), and delaying rehabilitation. This study aimed to explore the association of PKOS with pain, ROM, maximum voluntary contraction (MVC), and functional outcome after ACLR. Methods Thirty-two subjects undergoing ACLR were recruited for this study. PKOS, pain, ROM, and MVC were measured on days 0, 1, 2, 3, 2nd week, and 6th week, while functional outcome was assessed using the Lower Extremity Functional Scale (LEFS) after 2 weeks and 6 weeks. Girth measurement was taken to assess swelling, pain was assessed using a visual analog scale (VAS), and MVC was analyzed using surface electromyography ® . Results Mean values for PKOS, VAS, ROM, MVC, and functional outcome showed overall improvement from day 0 to week 6, except for MVC values, which exhibited fluctuations from day 2 to day 3. However, no significant association (p > 0.05) was found between PKOS and pain, ROM, MVC, and functional outcome. Conclusion While PKOS improved along with other variables over the recovery period, it exhibited no significant correlation with pain, ROM, strength, or functional outcome post-ACLR, warranting further investigation. Registration : Clinical Trial Registry (CTRI/2022/03/041101). READ ALL READ LESS Keywords Anterior cruciate ligament reconstruction, swelling, pain, maximum voluntary contraction, functional outcome Corresponding Author(s) Ashish John Prabhakar ( [email protected] ) Close Corresponding author: Ashish John Prabhakar Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Shenoy S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Shenoy S, Prabhakar AJ, Eapen C et al. Correlation between post-operative knee swelling and pain, maximal voluntary muscle contraction, and function following ACL reconstruction: a longitudinal study [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :818 ( https://doi.org/10.12688/f1000research.166364.1 ) First published: 26 Aug 2025, 14 :818 ( https://doi.org/10.12688/f1000research.166364.1 ) Latest published: 26 Aug 2025, 14 :818 ( https://doi.org/10.12688/f1000research.166364.1 ) Introduction Post-operative knee swelling (POKS) is a common impairment following anterior cruciate ligament reconstruction (ACLR) that can substantially affect recovery trajectories and long-term rehabilitation outcomes ( Ong et al., 2023 ). In Indian epidemiological studies, ACL injuries have been reported as the most frequent sports-related knee trauma among young male athletes ( John et al., 2016 ). ACL tears are among the most common ligament injuries of the knee and are often managed operatively, although nonoperative strategies remain viable in selected populations ( Bogunovic & Matava, 2013 ). ACL reconstruction remains the standard surgical approach for restoring knee stability and function in active individuals ( Musahl & Karlsson, 2019 ). Surgical stimuli can intensify the inflammatory cascade within the knee joint, leading to postoperative swelling. Additionally, the irrigation procedure conducted during ACLR, entailing the extraction of synovial fluid, could undermine joint lubrication, thus fostering an increase in knee swelling. Despite advancements in surgical techniques and rehabilitation protocols, PKOS remains elusive. Its association with pain, reduced range of motion (ROM), reduced quadriceps muscle strength, muscle inhibition, atrophy, and impaired functional outcomes remains poorly understood ( Kochhal et al., 2019 ). Swelling after ACLR is frequently linked with neuromuscular functional changes such as arthrogenic muscle inhibition (AMI), which is hypothesized to result from the inflammatory response triggered by tissue trauma associated with surgery ( Palmieri-Smith et al., 2013 ; Sonnery-Cottet et al., 2019 ). Recent studies have also shown persistent impairments in quadriceps neuromuscular control and physical function extending well beyond the early post-operative phase ( Hunnicutt et al., 2020 ). Non-contact ACL injuries, which are the most common type, are often attributed to faulty landing mechanics, muscle imbalances, and neuromuscular deficits ( Shimokochi & Shultz, 2008 ). AMI is typically characterized by reduced activation and motor unit output in the vastus medialis and vastus lateralis muscles, leading to poor treatment outcomes, including persistent range of motion and strength deficits, postoperative stiffness ( Palmieri-Smith et al., 2013 ; Sonnery-Cottet et al., 2019 ). Consequently, assessing maximum voluntary contraction (MVC) of these muscles using Electromyography (EMG) is essential to provide objective data on strength and activation of the quadriceps muscles. Documenting the changes in MVC values can indicate strength improvement or deficits, guiding the rehabilitation and monitoring patient progress. However, no previous study explored the association between PKOS and MVC over time in ACLR population. Previous studies demonstrated that knee swelling leads to significant quadriceps inhibition and strength deficits ( Palmieri-Smith et al., 2013 ). These findings are supported by a systematic review and meta-analysis confirming persistent deficits in quadriceps strength and volitional activation post-ACLR ( Lisee et al., 2019 ). However, these studies largely focus on experimentally induced knee effusion and do not fully capture the impacts of acute and chronic effects of PKOS following ACLR, including deficits in pain, ROM, MVC and strength due to AMI, persistent impact on functional outcomes. Another study reported that quadriceps strength deficit observed following ACLR is primarily due to muscle atrophy rather than neuromuscular inhibition ( Hobson, 2018 ). However, the study lacks objective measurement of maximum quadriceps strength and activation in the immediate postoperative period (<6 weeks). Return to sport following ACLR has been shown to be influenced by knee impairments, pain, and functional limitations in the early post-operative period ( Lentz et al., 2012 ). The need for this study arises from the recognized gap in the literature concerning the acute effects of post-operative swelling on key functional outcomes. While there is substantial evidence ( Palmieri-Smith et al., 2013 ; Palmieri et al., 2004 ) indicating that knee swelling negatively affects muscle strength and functional outcomes in the later stages of recovery, there is limited data on its impact during the immediate post-operative period ( Norte et al., 2018 ). Therefore, the purpose of this study is to examine the time course of PKOS following ACLR and its association with pain, ROM, MVC, and functional performance in people undergoing ACLR for primary ACL injury. Examining the association of PKOS of ACLR with pain, ROM, MVC, and functional performance early in the rehabilitation process is critical for developing targeted interventions that can enhance recovery trajectories. Targeted neuromuscular strategies aimed at restoring knee extensor strength are essential components of evidence-based ACLR rehabilitation ( Buckthorpe et al., 2019 ). Materials and methods Study design and participants The Department of Physiotherapy, Kasturba Medical College, Mangalore, conducted this longitudinal study from February 2022 to January 2023. Ethical approval was obtained from the Institutional Ethics Committee, KMC Mangalore (IEC KMC MLR01/2022/12), and the study was registered with India’s Clinical Trial Registry (CTRI/2022/03/041101). Thirty-two participants, aged between 15 and 55, who underwent ACLR were recruited (see Table 1 for demographics) and provided written informed consent, compliant with the latest revision of the Declaration of Helsinki. Participants who underwent ACLR with meniscal repair, had associated fractures, injuries to the collateral ligaments, intraoperative complications like fractures, or postoperative infections were excluded. The overall participant screening and allocation process is depicted in Figure 1 . Table 1. Demographic data (Age). Age Percent 20 and below 9.4 21-30 62.5 31-40 15.6 Above 40 12.5 Total 100.0 Procedure Following approval of the study, participants were recruited based on the eligibility criteria, and written informed consent was obtained from all participants. Demographic information for all participants was documented, and clinical assessments of PKOS, pain, ROM, and MVC were recorded on day 0, 1, 2, 3, during the 2nd week, and at the 6th week follow-up. The Lower Extremity Functional Scale (LEFS) was administered at the 2-week and 6-week intervals. Outcome measures PKOS: Circumferential measurements of the limb were taken using an inch tape at specific levels: at the joint line ( Figure 2 ), 5 cm superior ( Figure 3 ), 10 cm superior ( Figure 4 ), 15 cm superior ( Figure 5 ), and 15 cm inferior to the joint line ( Figure 6 ). These measurements are proven to have a high level of reliability in patients recovering from ACLR surgery ( Soderberg et al., 1996 ). Figure 1. Methodological flow chart. Figure 2. Girth measurement: At the joint line. Figure 3. Girth measurement: 5 cm superior to the joint line. Figure 4. Girth measurement: 10 cm superior to the joint line. Figure 5. Girth measurement: 15 cm superior to the joint line. Sensor placement for surface EMG: The placement of the electrodes was according to the SENIAM ® (Surface Electromyography for the Non-Invasive Assessment of Muscles) guidelines. The electrode for the rectus femoris is positioned on the imaginary line between the anterior superior iliac spine (ASIS) and the superior region of the patella at 50%. For the vastus medialis, the electrode is positioned at 80% on the line between the ASIS and the joint space in front of the anterior border of the medial ligament. The electrode for the vastus lateralis is positioned at the 2/3rd level on the line from the ASIS to the lateral side of the patella ( SENIAM, 2020 ). The electrode placements used to assess MVC are illustrated in Figure 7 . MVC testing protocol: After the placement of sensors, all participants were asked to perform MVC of the identified muscles for 5 seconds. Participants were verbally encouraged to push as hard as possible for 5 seconds and were permitted to view the computer monitor during the MVC trials for visual feedback and motivation. During this process, MVC was recorded over three trials. EMG analysis was performed following the standard procedure outlined in the operating manual of the Data LITE ® wireless system to determine the MVC of each muscle. The recorded data was rectified, and the MVC was documented using the Data LITE ® wireless system: Biometrics Ltd application. Each trial was repeated thrice to ensure adequate motor unit data capture. Each trial followed a trapezoidal waveform: three-second ramp up, ten-second sustained contraction at the designated %MVC, and three-second ramp down. Each participant was instructed to follow the trapezoid as closely as possible, with real-time visual feedback displayed on a computer monitor. Pain was assessed using the Visual Analog Scale (VAS), which has high test-retest reliability (ICC values ranging from 0.71 to 0.99) and moderate concurrent validity (0.71–0.78) ( Kahl & Cleland, 2005 ). ROM was measured using a standard long arm goniometer, which has high intra-tester reliability (0.99) and validity (0.98) ( Figures 8 & 9 ) ( Brosseau et al., 2001 ). Figure 6. Girth measurement: 15 cm inferior to the joint line. Figure 7. Placement of EMG sensors to record MVC. Figure 8. Starting position for goniometric knee flexion ROM. Figure 9. Measuring knee flexion ROM with goniometer. Figure 10. Age group of the subjects. Figure 11. Gender of the subjects. Figure 12. Mean values for VAS, on activity and at rest from day 0 to week 6. Figure 13. Mean values for girth measurements at 15 cm, 10 cm, 5 cm superior to the joint line, at the joint line and 15 cm below the joint line from day 0 to week 6. Figure 14. Mean values for knee flexion ROM (active and passive) from day 0 to week 6. Figure 15. Mean values for MVC of rectus femoris, vastus medialis and vastus lateralis from day 0 to week 6. The Lower Extremity Functional Scale (LEFS) was used to measure functional outcomes, with test-retest reliability coefficients ranging from 0.85 to 0.95 ( Cupido et al., 2014 ). Statistical analysis The study employed various statistical methods to analyze continuous variables related to knee swelling and its associations with pain, ROM, MVC and LEFS. All continuous variables including pain, ROM, MVC and LEFS were presented as means with standard deviations (SDs) using descriptive statistics. Pearson correlation coefficients (r) was utilized to determine the correlation between PKOS and pain, ROM, MVC, and LEFS for all time points. A p-value of less than 0.05 was considered statistically significant. All analyses were performed with IBM SPSS version 25.0 (Statistical Package for Social Sciences). Results The demographic characteristics of the study participants are summarized in Table 1 and Table 2 . Thirty-two subjects, comprising 27 males and 7 females, were recruited for the study, with a mean age of 28.47 ± 8.613 years ( Table 2 ). The age-wise distribution of participants is illustrated in Figure 10 . In Table 1 , the distribution of participants by age reveals that the majority (62.5%) fell within the 21–30 age range, followed by 31–40 years (15.6%), and participants aged 20 and below accounted for 9.4%. Those above 40 years constituted 12.5% of the sample. Table 2 displays the gender distribution, with males comprising the majority (84.4%) and females representing 15.6% of the total sample. The gender-wise distribution is depicted in Figure 11 . These findings suggest that the study sample predominantly consists of young to middle-aged adults, with a greater representation of males. Table 2. Demographic data (Gender). Gender Frequency Percent Female 5 15.6 Male 27 84.4 Total 32 100.0 PKOS (Knee Girth Measurement) Table 3 presents mean values for various girth measurements, VAS scores, knee flexion ROM measurements, MVC measurements, and LEFS scores. A notable trend observed across multiple parameters is a decrease in measurements as one moves superiorly from 15 cm above the joint line to 15 cm below the joint line on Day 0. This trend persists throughout the entire data collection period, spanning Days 1-3 and Weeks 1 and 2. Specifically, girth measurements, VAS scores, and knee flexion ROM measurements exhibit this pattern consistently. The trend of pain reduction over time is illustrated in Figure 12 . In contrast, MVC measurements for the rectus femoris, vastus medialis, and vastus lateralis muscles demonstrate a slight increase over the data collection period. Additionally, LEFS scores exhibit a general upward trend, indicating an overall improvement in lower extremity functional ability throughout the duration of the study. These trends in knee swelling reduction across anatomical sites and time points are visually depicted in Figure 13 . Table 3. Mean values for girth measured at 15 cm, 10 cm, 5 cm superior to the joint line, at the joint line and 15 cm below the joint line, VAS, knee flexion ROM, MVC for rectus femoris, vastus medialis, vastus lateralis and LEFS. N Girth measurement (Mean) VAS (Mean) Knee flexion ROM (Mean) MVC (Mean) LEFS (Mean) 15 cm superior 10 cm superior 5 cm superior At the joint line 15 cm below On activity At rest Active Passive Rectus femoris Vastus medialis Vastus lateralis Day 0 32 45.12 42.19 40.95 39.58 35.22 8.22 4.88 23.44 29.13 0.048 0.036 0.063 Day 1 32 45.08 42.12 40.88 39.49 35.13 6.78 3.16 37.34 43.53 0.071 0.058 0.095 Day 2 32 44.83 42.08 40.84 39.41 35.03 5.00 1.81 47.84 54.16 0.048 0.051 0.096 Day 3 32 44.76 42.02 40.80 39.33 34.94 3.59 1.16 55.56 63.16 0.060 0.071 0.094 Week 2 32 44.01 41.06 39.47 37.81 34.04 2.59 0.69 75.25 84.59 0.083 0.125 0.148 35.78 Week 6 32 43.29 40.16 38.19 36.63 33.45 1.25 0.19 96.63 105.09 0.249 0.513 0.553 60.95 Correlation between PKOS and Pain The correlation between PKOS as measured by girth at various locations around the knee, and clinical measures including pain (VAS), was examined from Day 0 to Week 6 post-surgery and is reported in Table 4 . Across all time points, there was no significant correlation between knee girth measurements at different locations and VAS scores for activity or at rest on Day 0, suggesting that swelling may not strongly correlate with pain immediately post-surgery. However, as time progressed, a negative correlation between knee girth measurements at superior locations (15 cm, 10 cm, and 5 cm above the joint line) and VAS scores for activity was observed, albeit not consistently significant. This indicates that as knee swelling decreases, pain during activity tends to decrease as well, though not in a statistically significant manner for most time points. Table 4. Correlation between girth of the knee and VAS, on activity and at rest from day 0 to week 6. Day VAS (activity) VAS (rest) N r value p value N r value p value Day 0 Girth- 15 cm superior 32 -0.001 0.994 32 0.176 0.334 Girth- 10 cm superior 32 -0.144 0.432 32 0.119 0.518 Girth- 5 cm superior 32 -0.165 0.365 32 0.104 0.571 Girth- At the joint line 32 -0.147 0.421 32 0.070 0.705 Girth- 15 cm below 32 -0.100 0.584 32 0.312 0.082 Day 1 Girth- 15 cm superior 32 -0.282 0.118 32 -0.067 0.714 Girth- 10 cm superior 32 -0.261 0.149 32 -0.038 0.838 Girth- 5 cm superior 32 -0.234 0.198 32 -0.015 0.935 Girth- At the joint line 32 -0.206 0.257 32 -0.001 0.995 Girth- 15 cm below 32 -0.328 0.067 32 0.007 0.970 Day 2 Girth- 15 cm superior 32 -0.256 0.158 32 0.257 0.155 Girth- 10 cm superior 32 -0.285 0.114 32 0.254 0.161 Girth- 5 cm superior 32 -0.289 0.108 32 0.189 0.300 Girth- At the joint line 32 -0.221 0.225 32 0.178 0.331 Girth- 15 cm below 32 -0.399 0.024 * 32 -0.009 0.960 Day 3 Girth- 15 cm superior 32 -0.351 0.049 * 32 0.132 0.472 Girth- 10 cm superior 32 -0.346 0.052 32 0.202 0.267 Girth- 5 cm superior 32 -0.374 0.035 * 32 0.189 0.300 Girth- At the joint line 32 -0.326 0.069 32 0.276 0.127 Girth- 15 cm below 32 -0.272 0.132 32 0.065 0.725 Week 2 Girth- 15 cm superior 32 -0.009 0.959 32 0.257 0.156 Girth- 10 cm superior 32 -0.028 0.879 32 0.248 0.172 Girth- 5 cm superior 32 -0.088 0.632 32 0.177 0.333 Girth- At the joint line 32 -0.115 0.529 32 -0.096 0.602 Girth- 15 cm below 32 -0.027 0.885 32 0.135 0.460 Week 6 Girth- 15 cm superior 32 -0.046 0.803 32 0.187 0.307 Girth- 10 cm superior 32 0.005 0.980 32 0.233 0.200 Girth- 5 cm superior 32 -0.006 0.973 32 0.194 0.287 Girth- At the joint line 32 0.162 0.374 32 0.230 0.206 Girth- 15 cm below 32 0.075 0.684 32 0.143 0.435 * Significant at p < 0.05. Correlation between PKOS and Knee flexion ROM Table 5 presents the correlation between knee girth and knee flexion ROM, both active and passive, from Day 0 to Week 6 post-surgery. The study documented active and passive knee flexion ROM from Day 0 to Week 6 post-surgery, showing gradual increases in mean values from 23.44 to 96.63 for active ROM and from 29.13 to 105.09 for passive ROM ( Table 5 ). Initially, in the early days following ACLR (Day 0-1), no significant correlations were found between knee girth and ROM. However, weak positive correlations emerged over time, particularly at superior locations above the joint line. Significantly, on Day 2, negative correlations suggested a potential link between decreased knee swelling and slight improvements in ROM (15 cm below: r = 0.218, p = 0.231). By Week 6, negative correlations became more pronounced, indicating a potential association between reduced swelling and improved ROM (15 cm superior: r = -0.384, p = 0.030* for active ROM). The progression in active and passive knee flexion over time is visually represented in Figure 14 . Table 5. Correlation between girth of the knee and knee flexion ROM (active and passive) from day 0 to week 6. Day ROM (Active) ROM (Passive) N r value p value N r value p value Day 0 Girth- 15 cm superior 32 0.141 0.443 32 0.121 0.511 Girth- 10 cm superior 32 0.204 0.263 32 0.173 0.345 Girth- 5 cm superior 32 0.211 0.247 32 0.195 0.284 Girth- At the joint line 32 0.267 0.140 32 0.263 0.146 Girth- 15 cm below 32 0.263 0.145 32 0.266 0.141 Day 1 Girth- 15 cm superior 32 0.103 0.576 32 0.067 0.715 Girth- 10 cm superior 32 0.111 0.545 32 0.083 0.652 Girth- 5 cm superior 32 0.089 0.630 32 0.065 0.725 Girth- At the joint line 32 0.171 0.349 32 0.154 0.401 Girth- 15 cm below 32 0.331 0.064 32 0.299 0.096 Day 2 Girth- 15 cm superior 32 -0.133 0.468 32 -0.110 0.549 Girth- 10 cm superior 32 -0.099 0.588 32 -0.076 0.681 Girth- 5 cm superior 32 -0.098 0.595 32 -0.067 0.715 Girth- At the joint line 32 -0.008 0.965 32 0.020 0.913 Girth- 15 cm below 32 0.133 0.469 32 0.157 0.391 Day 3 Girth- 15 cm superior 32 -0.121 0.508 32 -0.095 0.605 Girth- 10 cm superior 32 -0.081 0.659 32 -0.060 0.744 Girth- 5 cm superior 32 -0.033 0.859 32 -0.004 0.983 Girth- At the joint line 32 0.042 0.821 32 0.072 0.696 Girth- 15 cm below 32 0.121 0.511 32 0.109 0.553 Week 2 Girth- 15 cm superior 32 -0.148 0.418 32 -0.070 0.702 Girth- 10 cm superior 32 -0.204 0.263 32 -0.141 0.442 Girth- 5 cm superior 32 -0.143 0.435 32 -0.086 0.641 Girth- At the joint line 32 -0.022 0.904 32 0.012 0.950 Girth- 15 cm below 32 0.039 0.833 32 0.069 0.707 Week 6 Girth- 15 cm superior 32 -0.287 0.111 32 -0.347 0.052 Girth- 10 cm superior 32 -0.294 0.102 32 -0.374 0.035 * Girth- 5 cm superior 32 -0.277 0.124 32 -0.359 0.044 * Girth- At the joint line 32 -0.113 0.538 32 -0.233 0.199 Girth- 15 cm below 32 -0.263 0.147 32 -0.338 0.058 * Significant at p < 0.05. MVC Table 6 illustrates the correlation between knee girth and MVC of the rectus femoris, vastus medialis, and vastus lateralis muscles from Day 0 to Week 6 post-surgery. Initially, on Day 0, no significant correlations were observed between knee girth and MVC measurements for all three muscles. However, as the recovery progressed, weak and inconsistent correlations emerged, with some time points showing positive or negative correlations, while others showed no significant associations. At Week 6, however, negative correlations between knee girth and MVC measurements were statistically significant for all three muscles: rectus femoris (r = -0.384, p = 0.030*), vastus medialis (r = -0.438, p = 0.012*), and vastus lateralis (r = -0.433, p = 0.013*). These changes in muscle activity over time are illustrated in Figure 15 . Table 6. Correlation between girth of the knee and MVC of rectus femoris, vastus medialis and vastus lateralis from day 0 to week 6. Day Rectus Femoris Vastus medialis Vastus Lateralis N r value p value N r value p N r value p value Day 0 Girth- 15 cm superior 32 0.114 0.534 32 0.111 0.544 32 -0.035 0.848 Girth- 10 cm superior 32 0.109 0.552 32 0.070 0.703 32 -0.069 0.707 Girth- 5 cm superior 32 0.077 0.677 32 0.070 0.703 32 -0.115 0.531 Girth- At the joint line 32 0.036 0.844 32 -0.090 0.625 32 -0.086 0.639 Girth- 15 cm below 32 -0.088 0.633 32 -0.022 0.907 32 -0.003 0.985 Day 1 Girth- 15 cm superior 32 -0.038 0.835 32 0.004 0.983 32 -0.190 0.298 Girth- 10 cm superior 32 -0.105 0.566 32 0.011 0.954 32 -0.157 0.391 Girth- 5 cm superior 32 -0.116 0.528 32 -0.026 0.886 32 -0.164 0.371 Girth- At the joint line 32 -0.082 0.654 32 0.035 0.848 32 -0.146 0.424 Girth- 15 cm below 32 0.008 0.963 32 0.121 0.509 32 -0.111 0.547 Day 2 Girth- 15 cm superior 32 0.017 0.925 32 -0.059 0.749 32 -0.234 0.198 Girth- 10 cm superior 32 0.124 0.497 32 0.039 0.833 32 -0.120 0.513 Girth- 5 cm superior 32 0.058 0.751 32 0.078 0.671 32 -0.080 0.662 Girth- At the joint line 32 0.055 0.765 32 0.098 0.594 32 -0.048 0.794 Girth- 15 cm below 32 0.218 0.231 32 0.140 0.446 32 -0.041 0.823 Day 3 Girth- 15 cm superior 32 0.025 0.891 32 -0.259 0.152 32 -0.209 0.252 Girth- 10 cm superior 32 0.130 0.479 32 -0.189 0.300 32 -0.084 0.649 Girth- 5 cm superior 32 0.097 0.598 32 -0.146 0.424 32 -0.028 0.878 Girth- At the joint line 32 0.111 0.545 32 -0.088 0.633 32 0.047 0.799 Girth- 15 cm below 32 0.227 0.211 32 -0.047 0.800 32 0.074 0.689 Week 2 Girth- 15 cm superior 32 -0.098 0.593 32 -0.088 0.632 32 -0.013 0.943 Girth- 10 cm superior 32 -0.099 0.589 32 -0.085 0.645 32 0.008 0.963 Girth- 5 cm superior 32 -0.108 0.555 32 -0.144 0.431 32 -0.001 0.997 Girth- At the joint line 32 -0.039 0.832 32 0.011 0.954 32 0.018 0.924 Girth- 15 cm below 32 0.246 0.174 32 0.166 0.365 32 0.182 0.318 Week 6 Girth- 15 cm superior 32 -0.384 0.030 * 32 -0.438 0.012 * 32 -0.433 0.013 * Girth- 10 cm superior 32 -0.482 0.005 * 32 -0.456 0.009 * 32 -0.453 0.009 * Girth- 5 cm superior 32 -0.491 0.004 * 32 -0.427 0.015 * 32 -0.430 0.014 * Girth- At the joint line 32 -0.276 0.126 32 -0.204 0.263 32 -0.161 0.380 Girth- 15 cm below 32 -0.077 0.674 32 -0.129 0.481 32 -0.102 0.579 * Significant at p < 0.05. Correlation between PKOS and LEFS Table 7 presents the correlation between knee girth and LEFS from Day 0 to Week 6 post-surgery. At Week 2, no significant correlations were found between knee girth and LEFS scores at any measurement location. However, a positive correlation was observed between knee girth 15 cm below the joint line and LEFS scores (r = 0.176, p = 0.335). By Week 6, negative correlations between knee girth and LEFS scores were observed at several measurement locations. Specifically, significant negative correlations were found for knee girth 5 cm superior (r = -0.375, p = 0.034*) and knee girth at the joint line (r = -0.340, p = 0.057) Table 7. Correlation between girth of the knee and LEFS from day 0 to week 6. Day LEFS N r value p value Week 2 Girth- 15 cm superior 32 -0.134 0.465 Girth- 10 cm superior 32 -0.123 0.501 Girth- 5 cm superior 32 -0.148 0.418 Girth- At the joint line 32 -0.043 0.815 Girth- 15 cm below 32 0.176 0.335 Week 6 Girth- 15 cm superior 32 -0.254 0.160 Girth- 10 cm superior 32 -0.264 0.145 Girth- 5 cm superior 32 -0.375 0.034 * Girth- At the joint line 32 -0.340 0.057 Girth- 15 cm below 32 -0.200 0.273 * Significant at p < 0.05. . Discussion The objective of the study was to find an association between swelling at the knee joint with pain, ROM, muscle strength and functional outcome after ACLR. In our study, the maximum number of participants who underwent ACLR were from the age group of 20-30 years; this could be attributed to their active lifestyle in comparison to those of the other age ranges. There were more male than female participants in our study despite the fact that the incidence rates of ACL injury are reported to be 2.4–9.5 times higher in females ( Sanders et al., 2016 ; Lew et al., 2021 ). This could be as a result of higher participation of males than females in contact or high-intensity sports, which is considered as a risk factor for ACL injury ( Sanders et al., 2016 ). The findings of our study suggested that girth of the knee and VAS on activity and at rest decreased from day 0 to week 6, however no significant association was seen between the two parameters, it was also noted that muscle inhibition persisted with presence of swelling, similarly studies have also suggested that in the absence of pain, quadriceps inhibition was noted in knee with artificially induced swelling ( Hopkins & Ingersoll, 2000 ; Wood et al., 1988 ). Though the mechanism behind muscle inhibition has been poorly understood, it is believed that swelling on its own can cause considerable quadriceps AMI ( Rice & McNair, 2010 ; Rice et al., 2014 ). Studies have revealed that intra articular swelling significantly reduces EMG activation and H reflex amplitude despite the absence of structural injury, pain or joint effusion ( Wood et al., 1988 ; Rice et al., 2009 ) Additionally, joint infusion has been shown to significantly increase group II joint afferent discharge in animal studies by raising intra articular pressure and activating stretch and pressure-sensitive mechanoreceptors ( Grigg & Hoffman, 1982 ; Wood & Ferrell, 1984 ). In the spinal cord, group I non reciprocal (Ib) inhibitory interneurons are known to be excited by group II joint afferents, inhibiting quadriceps alpha motor neurons and preventing complete activation of the muscle ( Iles et al., 1990 ; Lundberg et al., 1978 ). Recent theoretical models further support these findings, emphasizing both spinal and supraspinal pathways contributing to persistent AMI and its impact on quadriceps activation ( Norte et al., 2021 ). This is further corroborated by findings from experimental joint effusion models, which show that both pre- and post-synaptic spinal inhibition play key roles in arthrogenic quadriceps suppression ( Palmieri et al., 2004 ). AMI takes a central role in the injury cycle. Athletes who sustain joint injuries have mobility and ROM deficiencies. Reduced ROM can be caused by pain, swelling, muscle spasms, or the inability of the muscles around the joint to contract effectively. This causes muscle atrophy, weakness, and a slower rate of functional recovery ( Hopkins & Ingersoll, 2000 ; Young, 1993 ). Recent studies have also shown that joint effusion can reduce corticomotor excitability of the quadriceps, contributing to persistent voluntary activation failure in the early phase of rehabilitation ( Lepley et al., 2015 ). In the present study, it was found that there was a statistically significant correlation between girth and passive ROM for knee flexion for week 6 when measured at 10 cm and 5 cm superior to the joint line. Though there was no statistically significant correlation noted between girth and ROM at other time points, there was an improvement in the knee flexion ROM from day 0 to week 6 which could be explained by the decreased levels of interstitial and intracapsular swelling following rehabilitation ( Wilk et al., 2022 ). LEFS values were measured after 2 weeks and 6 weeks and it was seen that the mean values for LEFS increased from week 2 to week 6 for all the subjects. Similar longitudinal improvements in LEFS scores following ACLR have been reported previously, reflecting functional recovery over early rehabilitation periods ( Alcock et al., 2012 ). However, the results showed that there was no association between girth measured at different points and LEFS after 2 weeks and 6 weeks. The reduction in ROM following ACLR is due to multifactorial reasons, furthermore, pain catastrophizing and kinesiophobia could play a role in active avoidance of movement due to fear of recurring pain or injury and this could impair daily functioning and can have a detrimental effect on rehabilitation outcomes in the long-term ( Österberg et al., 2013 ; Quartana et al., 2009 ). Patients may avoid actions that could potentially result in pain or re-injury which can in turn lead to unfavorable views towards one’s body and avoid participation in daily activities. After musculoskeletal injury and surgery, delayed recovery and discharge are frequently caused by pain catastrophizing and fear of pain ( Leeuw et al., 2007 ; Tichonova et al., 2016 ). A higher level of pain catastrophizing was highly correlated with a greater level of pain in the knee while performing activities of daily living before and after rehabilitation. A higher degree of kinesiophobia was strongly correlated with more difficulties experienced while carrying out daily activities ( Tichonova et al., 2016 ). In the present study, it was seen that MVC values for rectus femoris, vastus medialis and vastus lateralis showed a gradual increase from day 0 to week 6 except from day 2 to day 3. A significant correlation was observed between girth measured at 15 cm, 10 cm and 5 cm superior to the joint line and MVC for the muscles at 6 weeks whereas other measurements for girth from day 0 to week 6 showed no association with MVC for rectus femoris, vastus medialis and vastus lateralis. This could be possibly due to swelling and alterations in skin impedance which can give rise to artifacts influencing EMG readings ( Jun Kimura, 2013 ). Similarly, in a study done by Drechsler WI et al. (2006) , changes in isometric muscle strength, voluntary activation and EMG parameters were monitored in relation to pain, swelling and stability in the knee joint in 31 patients after ACLR and it was found that there was no association between quadriceps activation levels and swelling, which was measured at 1 and 3 months after ACLR ( Drechsler et al., 2006 ). The data from the current study supports this premise and expands on their work in that multiple factors could be responsible in influencing the MVC values after ACLR. Our study suggests that while swelling decreased over a period of time, parameters like pain, ROM, MVC and LEFS improved, but there was no statistically significant association found between these variables. These findings align with previous evidence showing that quadriceps function following ACLR may not always correlate directly with swelling or pain but can still influence patient-reported outcomes ( Lepley et al., 2018 ; Loyd et al., 2019 ). Furthermore, a recent longitudinal study further supported these trends, showing weak correlations between swelling and strength or function in the early weeks following ACL reconstruction ( Prabhakar, 2025 ). These observations highlight the clinical importance of restoring knee extensor strength through progressive neuromuscular rehabilitation after ACL reconstruction ( Buckthorpe et al., 2019 ). Conclusion The variables that were examined, including swelling, pain, ROM, MVC, and functional outcome, all improved overall, however swelling by itself had no significant correlation with any of the variables. Though swelling has its own effect that might influence the rehabilitation outcomes, its management should not be given any lesser importance. Therapeutic modalities such as neuromuscular electrostimulation have been shown to reduce post-operative knee effusion, pain, and swelling following ACL reconstruction, thus supporting the need for proactive swelling management ( Ediz et al., 2012 ). Ethical consideration The Department of Physiotherapy, Kasturba Medical College, Mangalore, conducted this longitudinal study from February 2022 to January 2023. Ethical approval was obtained from the Institutional Ethics Committee, KMC Mangalore (IEC KMC MLR01/2022/12), and the study was registered with India’s Clinical Trial Registry (CTRI/2022/03/041101). Data availability Open Science Framework (OSF): Correlation Between Post-Operative Knee Swelling and Pain, Maximal Voluntary Muscle Contraction, and Function Following ACL Reconstruction: A Longitudinal Study, 10.17605/OSF.IO/BKUX4 ( Prabhakar, A. J. 2025 ). 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 26 Aug 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Physiotherapy, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India 2 Institute of Physiotherapy Pandeshwar, Srinivas University City campus, Mangaluru, 575001, Karnataka, India 3 Department of Orthopedics, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India Shwetha Shenoy Roles: Investigation, Project Administration, Writing – Original Draft Preparation Ashish John Prabhakar Roles: Conceptualization, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing Charu Eapen Roles: Conceptualization, Supervision, Writing – Review & Editing Dias Tina Thomas Roles: Writing – Review & Editing Vijayakumar Palaniswamy Roles: Writing – Review & Editing Molly Cynthia Dsouza Roles: Supervision, Writing – Review & Editing Yogeesh Dattakumar Kamat Roles: Methodology, Project Administration, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 26 Aug 2025, 14:818 https://doi.org/10.12688/f1000research.166364.1 Copyright © 2025 Shenoy S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Shenoy S, Prabhakar AJ, Eapen C et al. Correlation between post-operative knee swelling and pain, maximal voluntary muscle contraction, and function following ACL reconstruction: a longitudinal study [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :818 ( https://doi.org/10.12688/f1000research.166364.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: AWAITING PEER REVIEW AWAITING PEER REVIEW ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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