Limb Symmetry Index: Chasing Equal Function
Considerations for Practitioners
- Review of the Research
- About the Author
Limb Symmetry Index (LSI) is a ratio between opposing limbs (e.g. right leg and left leg) that is commonly used within rehabilitation protocols, to compare an affected limb to (what would usually be) its unaffected counterpart (Palmieri-Smith et al., 2015).
It is calculated as follows:
(Affected limb value / un-affected limb value) * 100.
The LSI value is expressed as a percentage – the affected limb value as a percentage of the unaffected limb value. This value could represent numerous qualities such as strength in a particular muscle (e.g. the quadriceps) or performance in a hop test (e.g. single-leg vertical jump).
Since it’s an easy to calculate, inexpensive and flexible objective measure of limb symmetry that can be used for different tests throughout a rehabilitation protocol, there’s no surprise it’s so commonly used within clinical practice.
The use of LSI’s also removes the issue associated with progressing patients through their rehabilitation by being able to complete a certain number of repetitions in a particular exercise, which heavily relies on research in a very specific population.
Although LSI’s have many appealing advantages, they don’t come without their limitations. Not only are these limitations crucial to be aware of, but their potential implications require constant consideration and reinforcement within clinical settings.
Therefore, the aims of this Blog Post are to highlight the key considerations from peer-reviewed literature that practitioners should be aware of when using LSI’s in their everyday practice
Review of The Research
It is clear that there is abnormal limb symmetry following procedures such as anterior cruciate ligament reconstruction (ACLR) (Noyes et al., 1991). In uninjured populations, using LSI’s for measures such as knee extension and flexion range of motion, endfeel and effusion have previously demonstrated excellent reliability (Lawrance et al., 2016). However, the same study suggests that when LSI’s are used for hip adduction strength, scores can show larger variation.
In patients who have had an ACLR, there is reduced maximum voluntary activation bilaterally in the quadriceps (Urbach et al., 1999; 2001). This is further supported by Palmieri-Smith et al., (2008), who suggests that this may also be due to arthrogenic (reflex) muscle inhibition. Depending on the measure being assessed and the stage of rehabilitation, LSI ‘pass’ scores can typically vary from 80-95%.
Another study found that even 7-months post ACLR, both male and female participants who scored mean LSI’s of 95.4% across 3 different hop tests, their raw scores (e.g. jump distance) were still much lower when compared to healthy participants (Gokeler et al., 2017). This data further supports that there is true bilateral muscle weakness present following ACLR, which is highly neural.
These implications lead us on to another study, where participants who were pre-operative ACLR completed a quadriceps strength test and hop test to gather LSI scores, with the same testing administered 6-months post-op (Wellsandt et al., 2017). At 6-months post-op:
This means that even though participants scored 90% LSI 6-months post-op, over half still wasn’t at 90% of the level they were at before their operation. So, even though for some clinicians, this criteria may be a pass to progress rehabilitation, patients may not actually be at an acceptable level. This further supports the notion that there is bilateral quadriceps weakness following ACRL.
It also appears that LSI scores are significantly higher in a Single Hop for Distance and Triple Hop for Distance versus peak knee extension isokinetic torque and a bilateral power leg test (Nagai et al., 2020). This again is likely due to the decline in function of the unaffected limb (Patterson et al., 2020).
This body of research highlights the utmost importance of patients continuing to train their non-affected limb to maintain as much function as possible. This minimises the chance of LSI scores post-op underestimating knee function. It is crucial to encourage and reinforce this with patients, so they are committed to their rehabilitation.
Where possible, pre-operative testing is recommended to set a true benchmark (Davies et al., 2020). However, it’s important to consider when an ACL injury was diagnosed and how long the patients level of physical activity has been reduced, as this may have already resulted in a decline in function of the unaffected limb.
This also allows practitioners to take advantage of benefits such as cross-education. Providing a high neural training stimulus to an unaffected limb can also help reduce loss of neural function in the affected limb (Papandreou et al., 2013).
Limb Symmetry Index is an easy to calculate, inexpensive and flexible objective measure of limb symmetry that can be used for different tests throughout a rehabilitation protocol. It is also an effective method. However, for this to be true, The above limitations must be considered to ensure that affected limb function is not overestimated and true equal (or close to) function is achieved.
- Davies, W.T., Myer, G.D. and Read, P.J., 2020. Is it time we better understood the tests we are using for return to sport decision making following ACL reconstruction? A critical review of the hop tests. Sports Medicine, 50(3), pp.485-495.
- Gokeler, A., Welling, W., Benjaminse, A., Lemmink, K., Seil, R. and Zaffagnini, S., 2017. A critical analysis of limb symmetry indices of hop tests in athletes after anterior cruciate ligament reconstruction: a case control study. Orthopaedics & traumatology: surgery & research, 103(6), pp.947-951.
- Lawrance, S., Killian, C., Rundquist, P. and Jenkins, W., 2017. MEASURES OF LIMB SYMMETRY USED FOR INJURY RISK IDENTIFICATION: WHAT IS NORMAL?. British Journal of Sports Medicine, 51(4), pp.347-347.
- Nagai, T., Schilaty, N.D., Laskowski, E.R. and Hewett, T.E., 2020. Hop tests can result in higher limb symmetry index values than isokinetic strength and leg press tests in patients following ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 28(3), pp.816-822.
- Noyes, F.R., Barber, S.D. and Mangine, R.E., 1991. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. The American journal of sports medicine, 19(5), pp.513-518.
- Palmieri-Smith, R.M. and Lepley, L.K., 2015. Quadriceps strength asymmetry after anterior cruciate ligament reconstruction alters knee joint biomechanics and functional performance at time of return to activity. The American journal of sports medicine, 43(7), pp.1662-1669.
- Palmieri-Smith, R.M., Thomas, A.C. and Wojtys, E.M., 2008. Maximizing quadriceps strength after ACL reconstruction. Clinics in sports medicine, 27(3), pp.405-424.
- Papandreou, M., Billis, E., Papathanasiou, G., Spyropoulos, P. and Papaioannou, N., 2013. Cross-exercise on quadriceps deficit after ACL reconstruction. The journal of knee surgery, 26(01), pp.051-058.
- Patterson, Brooke E., Kay M. Crossley, Luke G. Perraton, Avnish S. Kumar, Matthew G. King, Joshua J. Heerey, Christian J. Barton, and Adam G. Culvenor. “Limb symmetry index on a functional test battery improves between one and five years after anterior cruciate ligament reconstruction, primarily due to worsening contralateral limb function.” Physical Therapy in Sport44 (2020): 67-74.
- Urbach, D.I.E.T.M.A.R., Nebelung, W.O.L.F.G.A.N.G., Weiler, H.T. and Awiszus, F.R.I.E.D.E.M.A.N.N., 1999. Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear. Medicine and science in sports and exercise, 31(12), pp.1691-1696.
- Urbach, D., Nebelung, W., Becker, R. and Awiszus, F., 2001. Effects of reconstruction of the anterior cruciate ligament on voluntary activation of quadriceps femoris: a prospective twitch interpolation study. The Journal of bone and joint surgery. British volume, 83(8), pp.1104-1110.