Functional Performance Testing and Patient Reported Outcomes following ACL Reconstruction: A Systematic Scoping Review

Objective. A systematic scoping review of the literature to identify functional performance tests and patient reported outcomes for patients who undergo anterior cruciate ligament (ACL) reconstruction and rehabilitation that are used in clinical practice and research during the last decade. Methods. A literature search was conducted. Electronic databases used included Medline, PubMed, Cochrane Library, EMBASE, CINAHL, SPORTDiscus, PEDro, and AMED. The inclusion criteria were English language, publication between April 2004 and April 2014, and primary ACL reconstruction with objective and/or subjective outcomes used. Two authors screened the selected papers for title, abstract, and full-text in accordance with predefined inclusion and exclusion criteria. The methodological quality of all papers was assessed by a checklist of the Critical Appraisal Skills Programme (CASP). Results. A total of 16 papers were included with full-text. Different authors used different study designs for functional performance testing which led to different outcomes that could not be compared. All papers used a measurement for quantity of functional performance except one study which used both quantity and quality outcomes. Several functional performance tests and patient reported outcomes were identified in this review. Conclusion. No extensive research has been carried out over the past 10 years to measure the quality of functional performance testing and control stability of patients following ACL reconstruction. However this study found that the measurement of functional performance following ACL reconstruction consisting of a one-leg hop for a set distance or a combination of different hops using limb symmetry index (LSI) was a main outcome parameter of several studies. A more extensive series of tests is suggested to measure both the quantitative and qualitative aspects of functional performance after the ACL reconstruction. The KOOS and the IKDC questionnaires are both measures that are increasingly being used for ACL reconstruction throughout the last decade.

The effect of videotape augmented feedback on drop jump landing strategy: Implications for anterior cruciate ligament and patellofemoral joint injury prevention

BACKGROUND

Modification of high-risk movement strategies such as dynamic knee valgus is key to the reduction of anterior cruciate ligament (ACL) and patellofemoral joint (PFJ) injuries. Augmented feedback, which includes video and verbal feedback, could offer a quick, simple and effective alternative to training programs for altering high-risk movement patterns. It is not clear whether feedback can reduce dynamic knee valgus measured using frontal plane projection angle (FPPA).

METHODS

Vertical ground reaction force (vGRF), two-dimensional FPPA of the knee, contact time and jump height of 20 recreationally active university students were measured during a drop jump task pre- and post- an augmented feedback intervention. A control group of eight recreationally active university students were also studied at baseline and repeat test.

RESULTS

There was a significant reduction in vGRF (p=0.033), FPPA (p<0.001) and jump height (p<0.001) and an increase in contact time (p<0.001) post feedback in the intervention group. No changes were evident in the control group.

CONCLUSION

Augmented feedback leads to significant decreases in vGRF, FPPA and contact time which may help to reduce ACL and PFJ injury risk. However, these changes may result in decreased performance.

CLINICAL RELEVANCE

Augmented feedback reduces dynamic knee valgus, as measured via FPPA, and forces experienced during the drop jump task and therefore could be used as a tool for helping decrease ACL and PFJ injury risk prior to, or as part of, the implementation of injury prevention training programs.

The reliability of biomechanical variables collected during single leg squat and landing tasks

INTRODUCTION

The aim of this study was to determine the within- and between-day reliability of lower limb biomechanical variables collected during single leg squat (SLS) and single leg landing (SLL) tasks.

METHODS

15 recreational athletes took part in three testing sessions, two sessions on the same day and another session one week later. Kinematic and kinetic data was gathered using a ten-camera movement analysis system (Qualisys) and a force platform (AMTI) embedded into the floor.

RESULTS

The combined averages of within-day ICC values (ICCSLS=0.87; ICCSLL=0.90) were higher than between-days (ICCSLS=0.81; ICCSLL=0.78). Vertical GRF values (ICCSLS=0.90; ICCSLL=0.98) were more reliable than joint angles (ICCSLS=0.85; ICCSLL=0.82) and moments (ICCSLS=0.83; ICCSLL=0.87).

DISCUSSION

This study demonstrates that all joint angles, moments, and vertical ground reaction force (GRF) variables obtained during both tasks showed good to excellent consistency with relatively low standard error of measurement values. These findings would be of relevance to practitioners who are using such measures for screening and prospective studies of rehabilitative techniques.

Knee valgus angle during single leg squat and landing in patellofemoral pain patients and controls

BACKGROUND

Patellofemoral pain (PFP) is a commonly presenting disorder of the lower limb, frequently effecting young physically active individuals particularly females. The condition has been associated with poor control of limb alignment while undertaking unilateral limb loading tasks. This poor alignment of the limb is believed to alter loading stress within the patellofemoral joint. This study aims to investigate the degree of knee valgus, assessed as 2D frontal plane projection angle (FPPA) during single leg squatting (SLS) and hop landing (SLL) tasks in patients with PFP and compare their performance to controls and the uninjured limb.

METHOD

Twelve female subjects with unilateral PFP formed the patient group and thirty asymptomatic females formed the control group. They had their 2D frontal plane projection angle (FPPA) assessed during single leg squatting (SLS) and hop landing (SLL) tasks.

RESULTS

In the asymptomatic control group the mean FPPA for SLS was 8.4±5.1° and SLL had a mean FPPA of 13.5±5.7°. In the PFP group the mean FPPA for SLS was 16.8±5.4° and SLL had a mean FPPA of 21.7+/-3.6°, these differences were significant (p<0.01) for both tasks.

CONCLUSION

Patients with PFP have a greater degree of knee valgus on unilateral limb loading task than either their contralateral asymptomatic limb or an asymptomatic control group. If not corrected this may lead to further PFJ stress and ongoing morbidity.

Cross-cultural adaptation, reliability, internal consistency and validation of the Arabic version of the knee injury and osteoarthritis outcome score (KOOS) for Egyptian people with knee injuries

OBJECTIVE

The objective of this study was to cross-culturally adapt and validate the Arabic version of the Knee injury and Osteoarthritis Outcome Score (KOOS) among a sample from Egyptian populace.

METHODS

This version was obtained with forward/backward translations and pre-testing. The Arabic KOOS, the RAND-36-Item Health Survey (RAND-36) questionnaire, visual analogue scales (VAS) of pain and a form for patient characteristics were used. Test-retest reliability and internal consistency were assessed, using Intraclass Correlation Coefficient (ICC) and Cronbach's alpha, respectively. The dimensionality was assessed, by factor analysis and construct validity by using a priori hypothesized correlations with the RAND-36. Ceiling/floor effects and measurement error were tested as well.

RESULTS

No major difficulties were encountered during the translation and pre-testing stages. Reliability was acceptable with Cronbach's alpha coefficients between 0.80 and 0.95, and ICCs ranging from 0.88 to 0.96 for the KOOS subscales. Factor analysis was performed on the whole study population and the results indicated that all items of the Arabic KOOS loaded on one factor, which ranged from 0.34 to 0.89. Construct validity was supported by the confirmation of all priori hypotheses by the presence of higher correlations between similar constructs than between dissimilar constructs of the KOOS subscales, RAND-36 subscales and VAS. Floor/ceiling effects were considered not to be present.

CONCLUSION

The Arabic KOOS is a reliable and valid instrument that can be self-administered to Egyptian patients and provides a valuable basis for research and clinical projects focussing on patient-based assessments in anterior cruciate ligament (ACL), meniscus and combined injures of knee. Further studies to validate the Arabic version of the KOOS using females and elderly population with different knee problems and various educational levels in other Arabic counties are highly recommended.

Does the change in Q angle magnitude in unilateral stance differ when comparing asymptomatic individuals to those with patellofemoral pain?

OBJECTIVE

To determine if Q angle changes in magnitude from bilateral stance when compared to unilateral stance and then if they are significantly different changes related to the presence of patellofemoral joint pain.

DESIGN

Observational correlation.

SETTING

University biomechanics laboratory.

PARTICIPANTS

60 Asymptomatic females and 12 females with patellofemoral joint pain.

MAIN OUTCOME MEASURE

Bilateral and unilateral stance Q angle.

RESULTS

Sixty females had their Q angles measured in bilateral and unilateral stance. Linear regressions showed predictive equations and positive correlations for unilateral and bilateral stance Q angles (r=0.81-0.89, p<0.001). The equations generated were used to predict unilateral Q angle from bilateral Q angle measurements in 12 patients with patellofemoral joint pain. The actual unilateral Q angle measurement of the symptomatic knee was significantly greater than that predicted for each individual (p=0.01), whilst the asymptomatic knee showed no significant difference (p=0.16).

CONCLUSION

This study showed a strong positive relationship between bilateral and unilateral stance Q angles which could be represented in a positive linear regression equation. The linear regression equation was then used to predict the effect on the Q angle of moving from a bilateral to a unilateral stance. It has been found previously that patients with patellofemoral joint pain on loading the limb in unilateral stance in activities such as walking and stair descent have increased knee valgus angle. The current study supports those findings indicating that when taking up unilateral stance patients with patellofemoral joint pain demonstrate greater than expected increase in Q angle which could increase loading on the patellofemoral joint.

Intra and inter-tester reliability of the tuck jump assessment

OBJECTIVE

To assess the inter-tester and intra-tester reliability of the tuck jump test.

DESIGN

Repeated measures.

SETTING

University Human Performance laboratory.

PARTICIPANTS

Five male and 5 female athletes undertook the Tuck jump test which was then assessed by two independent assessors.

MAIN OUTCOME MEASURES

Score from the video assessment of the tuck jump test by two independent assessors on two separate occasions.

RESULTS

Average percentage of exact agreement (PEA) between the two testers across all scoring criteria for all subjects was 93% (range 80-100%). Both testers were in absolute 100% agreement in 5 out of 10 subjects for all of the scoring criteria. The kappa measure of agreement was k = 0.88 which is very good/excellent. The intra-tester PEA ranged 87.2%-100%, with kappa values of k = 0.86-1.0.

CONCLUSION

The study showed very good-excellent intra-tester and inter-tester reliability for both examiners when comparing their individual scores of the tuck jump test across two analysis sessions. These findings indicate that the proposed tuck jump assessment is reliable to identify abnormal landing mechanics.

The effect of hip adduction angle on patellar position measured using real time ultrasound scanning

INTRODUCTION

There are limited in vivo studies investigating the influence of the Iliotibial Band (ITB) on patellar position, despite numerous references in the literature to this relationship. The purpose of this study was to investigate how the ITB influences patellar position, in vivo, indirectly through alteration of frontal plane hip position.

METHOD

Twelve healthy, asymptomatic, male subjects (age 23 ± 2.6 years) had their patellar position examined using real time ultrasound scanning. The knee was passively placed into 20° flexion and combined with hip neutral, 20° hip adduction and 20° hip abduction. Mean patellar position (distance from the lateral border of the patella to the edge of the intersection of the trochlear groove and lateral femoral condyle) was measured, with the smaller values representing a position whereby the patella is drawn more laterally and closer to the lateral femoral condyle.

RESULTS

Mean patellar position for neutral was 8.1mm (± 1.72 mm). Following 20° hip abduction the mean patellar position was 8.9 mm (± 1.7 9 mm), this was a statistically significant change in patellar position (p=0.003). Following 20° hip adduction the mean patellar displacement was 7.3mm (± 1.4mm) which, again, was a statistically significant change in patellar position (p=0.009). The results indicate that with the hip adduction the patella was positioned significantly more laterally (smaller value for distance).

DISCUSSION

The results of this study support the hypothesis that hip adduction which is likely to create loading and lengthening of the ITB causes significantly greater lateral displacement of the patella, than when the hip is abducted and the ITB unloaded.

Comparison of landing knee valgus angle between female basketball and football athletes: possible implications for anterior cruciate ligament and patellofemoral joint injury rates

OBJECTIVE

To evaluate landing strategies of female football and basketball athletes with relation to possible injury mechanisms and disparity in injury.

DESIGN

Descriptive laboratory study.

PARTICIPANTS

52 female football players and 41 female basketball players.

MAIN OUTCOME MEASURES

Frontal plane projection angle (FPPA) was measured during the single leg land (SLL) and drop jump (DJ) screening tasks.

RESULTS

2 × 2 × 2 mixed factorial ANOVA showed significant main effects were observed for sport, whilst significant interaction effects were seen between sport and task. Females in both sports exhibited significantly greater FPPA values during the SLL task than the DJ task (p < 0.001). Basketball players demonstrated significantly greater FPPA values during SLL than football players (p < 0.001), whilst no differences were found between sports in the DJ task (p = 0.328).

CONCLUSION

Female basketball players display greater FPPA values during unilateral landing tasks than female football players which may reflect the greater ACL injury occurrence in this population. Injury prevention programs in these athletes should incorporate unilateral deceleration and landing tasks and should consider the specific injury mechanisms in each sport.

Variation in pelvic morphology may prevent the identification of anterior pelvic tilt

Pelvic tilt is often quantified using the angle between the horizontal and a line connecting the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS). Although this angle is determined by the balance of muscular and ligamentous forces acting between the pelvis and adjacent segments, it could also be influenced by variations in pelvic morphology. The primary objective of this anatomical study was to establish how such variation may affect the ASIS-PSIS measure of pelvic tilt. In addition, we also investigated how variability in pelvic landmarks may influence measures of innominate rotational asymmetry and measures of pelvic height. Thirty cadaver pelves were used for the study. Each specimen was positioned in a fixed anatomical reference position and the angle between the ASIS and PSIS measured bilaterally. In addition, side-to-side differences in the height of the innominate bone were recorded. The study found a range of values for the ASIS-PSIS of 0-23 degrees, with a mean of 13 and standard deviation of 5 degrees. Asymmetry of pelvic landmarks resulted in side-to-side differences of up to 11 degrees in ASIS-PSIS tilt and 16 millimeters in innominate height. These results suggest that variations in pelvic morphology may significantly influence measures of pelvic tilt and innominate rotational asymmetry.

The effects of 4 weeks of jump training on landing knee valgus and crossover hop performance in female basketball players

Female basketball players would appear particularly prone to knee injuries. These injuries have been associated with the nature of the sport, but more specifically with the particular movement strategies adopted. A valgus or abducted position of the knee on landing has been reported to be associated with a number of different knee injuries. Jump-training programs have been reported to improve both landing knee valgus and functional performance. The majority of the jump-training programs have been of 6 weeks' duration, 3 sessions per week often lasting up to 1 hour. For most sports coaches, team conditioners, and athletes, this duration and program length is not acceptable. The aim of this study was to assess if an abridged jump-training program could have similar effects to those previously reported. Fifteen female basketball players had their knee valgus angles assessed during 2 landing tasks, drop jump landing, and when undertaking a jump shot and along with crossover hop distance before and after a progressive jump-training program. The jump-training program lasted 4 weeks, 3 times per week, each session lasting 15 minutes. After training, crossover hop distance showed an average percentage improvement on distance jumped of 73.6% (p = 0.001); the drop jump knee valgus angle in the left leg on average was reduced by 9.8° (p = 0.002), right leg reduced by 12.3° (p = 0.0001); during the jump shot, the knee valgus angle in the left leg showed a mean reduction of 4.5° (p = 0.035), and the right leg was reduced by 4.3° (p = 0.01). The study undertaken achieved comparable results to those previously reported with an abridged program over considerably shortened session duration and training period.

The effect of patellar taping on patellar position measured using ultrasound scanning

Previous research into the effect of patellar taping has found conflicting results and when studies have found positive findings these effects appear to be negated by exercise. The purpose of this study was to re-examine the effect of patellar taping on patellar position using ultrasound scanning. Twelve asymptomatic subjects (six males and six females (age 20.4+/-1.2 years)) had their patellar position examined, prior to and following the application of tape, and also following exercise (25 step ups). Mean patellar position (distance border patella to edge lateral femoral condyle) prior to application of tape was 6.2+/-1.3 mm following the application of tape mean patellar position was 7.9+/-1.7 mm, this was a statistically significant change in position (p=0.003). Following exercise mean patellar position was 7.6+/-1.7 mm this was a significant reduction compared to the taped position prior to exercise (p=0.001). This value was though still significantly greater than prior to the application of tape (p=0.006). This study found that patellar position was significantly changed following the application of tape. Furthermore, the study found that though low intensity exercise resulted in a significant change in the patellar position compared to the taped position prior to exercise, that change was most likely to have occurred due to random chance or measurement error.

A comparison of Star Excursion Balance Test reach distances between ACL deficient patients and asymptomatic controls

ACL injury has been associated with a decrease in proprioceptive performance and specifically postural control. Tests of postural control have been criticised for not being sufficiently challenging. The Star Excursion Balance Test (SEBT) has been proposed to offer sufficient challenge to be a sensitive test for detecting performance deficits related to pathology. The purpose of this study was to determine if decrements SEBT reach distance is associated with ACL deficiency (ACLD). Twenty five ACLD patients ACLD (17 male and 8 female, mean age 30 (SD 4.5) years) and twenty five matched controls were examined carrying out the SEBT. Factorial ANOVA showed the main effects of limb (p=0.006) and direction (p<0.001) and interaction of limb and direction (p=0.015) all had significant differences between the groups. Further analysis revealed significant differences between the control group and the ACLD limb for the limb movement directions of anterior (p=0.0032), lateral (p=0.005), posterior-medial (p=0.0024) and medial (p=0.001). There were also significant differences between the control limbs and uninjured limb of the patients for the directions of medial (p=0.001) and lateral (p=0.001). ACLD patients appear to have deficiencies in their dynamic postural control when compared to normal asymptomatic subjects. Interestingly, in the ACLD patients, their uninjured leg show deficits compared to the control in two of the four directions the ACLD leg was deficient, this may be indicative of a postural control deficit in these patients, which may have predisposed to the ACL injury and would warrant further study.