Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices

Anterior Cruciate Ligament Injury Does Not Increase the Risk for a Future Concussion: A Unidirectional Phenomenon

CONTEXT

Epidemiological studies have shown an increased risk of musculoskeletal injury after concussion. The purpose of this study was to determine whether the reverse relationship exists, specifically whether there is an increased risk of concussion after an anterior cruciate ligament (ACL) injury in a population-based cohort.

DESIGN

Retrospective cohort.

METHODS

The Rochester Epidemiology Project was searched between 2000 and 2017 for International Classification of Diseases, 9th and 10th Revision codes relevant to the diagnosis and treatment of concussion and ACL tear. A total of 1294 unique patients with acute, isolated ACL tears and no previous history of concussion were identified. Medical records for cases were reviewed to confirm ACL tear diagnosis and to determine history of concussion after the ACL injury. Cases were matched by age, sex, and Rochester Epidemiology Project availability to patients without an ACL tear (1:3 match), resulting in 3882 controls. Medical records of matched control patients were reviewed to rule out history of ACL injury. The hazard ratio of concussion injury following an ACL injury was determined.

RESULTS

Nine patients with an ACL injury suffered concussion up to 3 years after the ACL injury. The rate of concussion was no different between ACL-injured cases (0.7%) compared with matched controls with no ACL injury (1.2%), which corresponded to a hazard ratio of 0.55 (95% confidence interval, 0.3-1.1; P = .10).

CONCLUSIONS

Based on the current evidence, there does not appear to be a significant association between ACL injury and subsequent concussion, which suggests that a concussion uniquely affects the risk of future subsequent musculoskeletal injury.

Nurse-Assisted Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction

Despite significant advancements in surgical instruments and operation skills, short- and long-term outcomes following anterior cruciate ligament reconstruction (ACLR) remain unsatisfactory, as many patients fail to return to their pre-injury level of sports. Inadequate ACL rehabilitation is the primary cause of poor outcomes. Nurses have become a crucial element in the rehabilitation process. Although there is no consensus regarding the optimal post-operative rehabilitation protocols, restoring muscle strength and neuromuscular control are consistently the primary goals. This literature review presents nurse-assisted rehabilitation protocols aiming at improving muscle strength and neuromuscular control. The review discusses postoperative rehabilitation, including home-based and supervised rehabilitation, open and closed kinetic chain exercises, eccentric and concentric training, blood flow restriction training, and plyometric training. Each training protocol has its benefits and drawbacks, and should be used cautiously in specific stages of rehabilitation. Neuromuscular training, such as neuromuscular electrical stimulation, neuromuscular control exercises, and vibration therapy, is considered crucial in rehabilitation.

No Association Between Injury-Related Fear and Isokinetic Quadriceps Strength in Individuals With a History of Anterior Cruciate Ligament Reconstruction

CONTEXT

Injury-related fear and quadriceps strength are independently associated with secondary anterior cruciate ligament (ACL) injury risk. It is not known whether injury-related fear and quadriceps strength are associated, despite their individual predictive capabilities of secondary ACL injury. The purpose of this study was to examine the association between injury-related fear and quadriceps strength in individuals at least 1 year after ACL reconstruction (ACLR).

DESIGN

Cross-sectional study.

METHODS

Forty participants between the ages of 18 and 35 years at least 1 year post unilateral primary ACLR. Participants completed the Tampa Scale of Kinesiophobia-11 (TSK-11) and a standard isokinetic quadriceps strength assessment using the Biodex Isokinetic Dynamometer. Pearson Product-Moment correlations were used to examine the linear association between the TSK-11 scores and peak torque (in nanometers per kilogram) for each limb and between the TSK-11 scores and limb symmetry indices for each limb. Pearson Product-Moment correlation coefficients (r) were interpreted as very high (.90-1.00), high (.70-.90), moderate (.50-.70), low (.30-.50), and no correlation (.00-.30).

RESULTS

The average TSK-11 score was 18.2 (5.3), average ACLR peak quadriceps torque was 1.9 (0.50) N·m/kg, average contralateral peak quadriceps torque was 2.3 (0.48) N·m/kg, and average limb symmetry index was 85.3% (12.6%). There was no statistically significant correlation between the TSK-11 and peak quadriceps torque on the ACLR limb (r = .12, P = .46), the TSK-11 and contralateral limb (r = .29, P = .07), or the TSK-11 and limb symmetry index (r = -.18, P = .27).

CONCLUSIONS

There was no association between kinesiophobia and peak isokinetic quadriceps strength in individuals at least 1 year post-ACLR. Both factors, independently, have been shown to influence risk of secondary injury in patients after ACLR.

Functional outcomes of accelerated rehabilitation protocol for anterior cruciate ligament reconstruction in amateur athletes: a randomized clinical trial

BACKGROUND

Anterior cruciate ligament (ACL) rupture is the most common knee injury among athletes, and can result in long-term complications and career-ending conditions for sportspeople. There is no consensus in the literature on the effectiveness of rehabilitation after ACL reconstruction, or the best protocol to follow for functional outcome improvement.

OBJECTIVE

To determine the impact of an accelerated rehabilitation protocol on knee functional outcomes in amateur athletes with anterior cruciate ligament reconstruction (ACLR).

DESIGN

Two-arm, parallel-group randomized comparative design.

PATIENTS

A total of 100 amateur male athletes (mean age 22.01 ± 1.79 years) with ACLR were randomly divided into experimental and control groups (n = 50/group).

METHODS

An accelerated rehabilitation protocol and a conventional rehabilitation protocol were used for the experimental group. In contrast, only the conventional rehabilitation protocol was used for the control group. The rehabilitation was delivered in 5 weekly sessions for 22 weeks. The primary outcome measure, knee pain, was measured using a visual analogue scale (VAS). Extensive test batteries, for hop tests, Knee Injury and Osteoarthritis Outcome Score (KOOS), and knee effusion, were measured, aiming to add more objective criteria to determine functional performance.

RESULTS

Both groups (n = 50/group) were well-matched (p = 0.816), with insignificant differences in their demographic characteristics (p > 0.05). A multivariate analysis of variance (MANOVA) test showed no significant difference between the 2 groups (p = 0.781) at baseline. A 2-way MANOVA (2 × 2 MANOVA) of within- and between-group variations indicated overall significant treatment, time, and treatment × time interaction effects (p < 0.001) in favour of the accelerated rehabilitation group.

CONCLUSION

The accelerated rehabilitation protocol was more effective in improving functional outcomes than a conventional rehabilitation protocol in amateur athletes with ACLR.

Anterior Cruciate Ligament Injury Prevention and Rehabilitation

At all levels of American football, knee injuries are common, with injuries to the anterior cruciate ligament (ACL) making up a significant proportion. Historically, ACL injuries were career-altering for professional players, but innovative techniques in surgery and rehabilitation have returned many to the field. While there is a consensus on surgical techniques for ACL reconstruction, significant discrepancies remain on injury prevention and rehabilitation programs. This review article describes the burden of ACL injury on players in the National Football League, best practices in injury prevention and rehabilitation, and evidence-based recommendations for preparing injured athletes to return to play.

Functional outcomes of a criterion-based rehabilitation protocol for anterior cruciate ligament reconstruction in amateur athletes: A randomised clinical trial

INTRODUCTION

Although current rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR) are based on the graft remodeling process, there is uncertainty about its time schedule. Moreover, there are individual differences in neuromotor learning and flexibility after ACLR. The current study was conducted to investigate the functional outcomes of the criterion-based rehabilitation protocol in amateur athletes following ACLR.

METHODS

Fifty amateur male athletes who had ACLR were assigned randomly into two equal groups. The experimental group received a criterion-based rehabilitation protocol. The control group received a conventional physical therapy program. Both groups had five treatment sessions per week for six months. The primary outcome was pain intensity measured by VAS. Secondary outcomes included functional assessments measured by the limb symmetry index (LSI) of the hop test battery, knee effusion, and the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Mixed-design-MANOVA indicated significant treatment, time, and treatment × time interaction. The interaction was significant for all outcome measures in favor of subjects who received a criterion-based rehabilitation protocol. Within-group analysis revealed a significant reduction in pain in both groups and improvements in all variables related to the KOOS or LSI of the hop test battery. Knee effusion was significantly reduced post-treatment in patients who received a criterion-based protocol when compared to their controls.

CONCLUSIONS

Although application of a criterion-based rehabilitation protocol for 6 months after ACLR is more effective than a conventional program, its duration should be expanded beyond this period to allow patients to reach their return to play goals.

Evaluation of Isokinetic Knee Strengths after ACL Reconstruction with Quadrupled Semitendinosus Suspensory Femoral and Tibial Fixation versus Four-Strand Semitendinosus and Gracilis Suspensory Femoral and Tibial Screw Fixation

INTRODUCTION

The purpose of this study was to demonstrate that patients undergoing ACL reconstruction with quadrupled semitendinosus suspensory femoral and tibial fixation have comparable results in muscle strength and knee function to those undergoing ACL reconstruction with four-strand semitendinosus-gracilis suspensory femoral fixation and a bioabsorbable tibial interference screw fixation.

MATERIALS AND METHODS

Between 2017 and 2019, 64 patients who were operated on by the same surgeon were included. Patients underwent ACL reconstruction technique with quadrupled semitendinosus suspensory femoral and tibial button fixation in Group 1, and patients underwent ACL reconstruction with coupled four-strand semitendinosus-gracilis suspensory femoral fixation and a bioabsorbable tibial interference screw in Group 2. Evaluation of patients was performed with the Lysholm and Tegner activity scale preoperatively and at the 1st and 6th months postoperatively. At the 6-month visit, isokinetic testing of the operated and non-operated limbs was performed in both groups.

RESULTS

There was no significant difference in the age, weight, and BMI values of the patients in Groups 1 and 2 (p < 0.05). According to the strength values of the operated sides of the patients in Group 1 and Group 2, there was no significant difference in the angular velocities of 60° s^-1, 180° s^-1, and 240° s^-1 in both extension and flexion phases between the operated sides of Groups 1 and 2 (p < 0.05).

CONCLUSIONS

Patients who have ACL reconstruction with quadrupled semitendinosus suspensory femoral and tibial fixation have comparable muscle strength and knee function to those who undergo ACL reconstruction with four-strand semitendinosus-gracilis suspensory femoral fixation and a bioabsorbable tibial interference screw.

Evaluation of a smartphone application for self-rehabilitation after anterior cruciate ligament reconstruction during a COVID-19 lockdown

BACKGROUND

Rehabilitation after surgery is a crucial process that governs the final functional outcome. The self-rehabilitation smartphone application Doct'up (Healing SAS, Lyon, France) is designed for patients who have had anterior cruciate ligament (ACL) reconstruction surgery. In France in the spring of 2020, the lockdown mandated due to the COVID-19 pandemic prevented patients from seeing their physiotherapists for 2 months. The objective of this study was to compare the clinical outcomes in two groups of patients who underwent ACL reconstruction surgery: in one group, surgery performed before the lockdown was followed by standard in-person physiotherapy while, in the other, surgery was done just before the lockdown and rehabilitation was performed by the patients themselves using the phone application.

HYPOTHESIS

Using a self-rehabilitation smartphone app limits the negative effects of not receiving physiotherapist rehabilitation after ACL reconstruction.

MATERIAL AND METHODS

We performed a case-control study involving the retrospective analysis of prospectively collected data from two groups of patients who had undergone ACL reconstruction surgery. Patients in the App group had surgery just before the 2-month COVID-19-related lockdown that started in France on March 17, 2020,and used only the smartphone app for rehabilitation. The standard-care group was composed of matched controls who had surgery 1 year before the cases and received rehabilitation therapy during in-person physiotherapist visits. The ACL reconstruction technique was the same in the two groups. The primary outcome measure was extension lag 6 weeks after surgery. The secondary outcome measures were extension lag 3 weeks and 6 months after surgery, quadriceps muscle activation, knee extension locking 3 and 6 weeks after surgery, and the 6-month rate of surgical revision for cyclops syndrome.

RESULTS

We included 32 cases managed using only self-rehabilitation guided by the phone app, and we identified 101 matched controls managed using standard care. We found no significant between-group difference in extension lag after 6 weeks: 9.4% (28/32) vs. 4.6% (87/101), p=0.39. After 3 weeks, the App group had a higher proportions of patients with quadriceps activation (94% [30/32] vs. 73% [74/101], p=0.015) and extension control using canes (78.1% [25/32] vs. 40.6% [41/101], p=0.0002). None of the other measured outcomes differed significantly between the two groups (extension lag after 3 weeks: 12.5% [4/32] vs. 13.8% 14/101]; extension lag after 6 months: 3.2% [1/32] vs. 1% [1/101]; quadriceps activation after 6 weeks: 97% [31/32] vs. 99% [100/101]; extension locking with canes after 6 weeks: 96.9% [31/32] vs. 93.1% [94/101]; extension locking without canes after 3 weeks: 53.2% [17/32] vs. 47.5% [48/101]; extension locking without canes after 6 weeks: 93.7% [30/32] vs. 82.2% [83/101]; and surgery for cyclops syndrome (3.1% [1/32] vs. 1% [1/101]).

DISCUSSION

The use of a self-rehabilitation phone app after ACL reconstruction during a COVID-19 lockdown limited the adverse effects of not receiving in-person physiotherapy. The 6-month outcomes were similar to those seen with standard rehabilitation. The study results demonstrate the usefulness of self-rehabilitation after ACL reconstruction surgery. Self-rehabilitation guided by a phone app could be used as a complement to the protocols generally applied by physiotherapists.

LEVEL OF EVIDENCE

IV, single-centre retrospective case-control study.

Recovery of Quadriceps Strength and Knee Function Using Adjuvant EMG-BF After Primary ACL Reconstruction

Introduction: Immobility and limited usage of operated limbs lead to weakness and atrophy of the muscle after anterior cruciate ligament (ACL) reconstruction. However, training programs for preventing biomechanical risk factors such as lower limb alignment and increased muscular contraction are very limited. Thus, the current study was carried out to evaluate the recovery of quadriceps muscle strength and the improvement of knee function using adjuvant electromyographic biofeedback (EMG-BF) after ACL reconstruction. Methods: This prospective randomized controlled trial was conducted among 40 patients (20=EMG-BF group, 20=Control group) with ACL reconstruction, who were referred to Akhtar Hospital from 2021 to 2022. In the EMG-BF group, EMG BFB was added to the standard rehabilitation protocol, and in the control group, the standard rehabilitation protocol with full postoperative weight-bearing, knee brace (zero degree of extension, 90 degrees of flexion), and electrical stimulation with maximal voluntary isometric knee extension was performed. Each group was intervened for 4 weeks and three sessions of 30 minutes per week. It should be noted that each patient participated in 16 outpatient physiotherapy sessions after surgery. Nicholas Hand-Held Dynamometer (HHD) was used for measuring quadriceps strength, and Knee Outcome Survey-Activities of Daily Living (KOS-ADLs) and Knee Outcome Survey Sports Activities Scale (KOS-SAS) questionnaires were used for assessing the knee function. Results: Four weeks after the treatment, the EMG-BF group showed a significant increase in quadriceps strength (P=0.0001). Quadriceps strength had a significant difference before and after 4 weeks of intervention (P=0.0001), but in the control group, no significant difference was observed (P=0.368). The EMG-BF group had a significant increase in KOS-ADLs and KOS-SAS scores after 4 weeks of intervention (P=0.0001). Conclusion: In our study, isometric strengthening of quadriceps with adjuvant EMG-BF significantly increased the strength of quadriceps and knee function during 4 weeks. EMG-BF is a low risk, low cost, and less invasive intervention and has high safety and adjustment ability. It is a valuable adjuvant method for achieving better functional recovery in a shorter time.

The development of long-term osteoarthritis following anterior cruciate ligament injury: reconstruction vs no reconstruction

PURPOSE

The high incidence of osteoarthritis (OA) in relatively young sportspeople following anterior cruciate ligament (ACL) reconstruction is concerning. Surgery is considered to reduce the development of OA compared to conservative management. This long-term study aimed to compare the incidence and severity of tibiofemoral OA (TFOA) and patellofemoral OA (PFOA) between reconstructed and non-reconstructed treatment groups and to determine which factors influence the development of OA.

MATERIALS AND METHODS

Fifty-six ACL-reconstructed and 45 conservatively treated patients from a cohort of 330 were followed for 11 years (mean) post-injury. Twenty-nine patients had received a bone-patellar tendon-bone (B-PT-B) graft, and 27 had received a hamstring (semitendinosus/gracilis) tendon (HT) graft. Assessment included objective and subjective stability, quadriceps and hamstring strength and radiology. Chi-square analyses compared OA between reconstructed and non-reconstructed groups and between B-PT-B, HT and non-surgical groups. Further analysis assessed the relationship between OA and age, time post-injury, meniscal injury/meniscectomy, quadriceps strength, hamstring strength, objective and subjective stability and sporting activity.

RESULTS

Forty-eight per cent reconstructed  and 53% non-reconstructed patients developed TFOA (p = 0.690). Thirty-six per cent reconstructed and 38% non-reconstructed patients developed PFOA (p = 0.831) with moderate PFOA occurring only in the non-reconstructed group. Close to significant differences (p = 0.075) were found comparing the severity of TFOA between groups with a higher incidence of moderate/severe OA in the non-reconstructed and B-PT-B groups. TFOA differed significantly between the B-PT-B and HT groups. The development of OA was related to age, time post-injury, meniscal injury/meniscectomy, quadriceps strength and subjective stability.

CONCLUSIONS

There were no significant differences in OA incidence between reconstructed and non-reconstructed groups but fewer patients developed TFOA following HT grafting compared to B-PT-B grafting and to non-surgical treatment. Quadriceps weakness and meniscal injuries/meniscectomy, both potentially modifiable, were strongly associated with the development of TF and PFOA.

Inertial Flywheel Resistance Training in Tendinopathy Rehabilitation: A Scoping Review

Background

Inertial Flywheel Resistance Training (IFRT) has recently emerged as a beneficial rehabilitation option for some musculoskeletal disorders. Although the use of resistance training as treatment for tendinopathy has become widespread, it is unclear if IFRT has efficacy as a treatment option for tendinopathies.

Objective

To identify current evidence on IFRT in the treatment of tendinopathy, evaluating intervention parameters and outcomes.

Methods

This scoping review was reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Databases searched included MEDLINE, CINAHL, AMED, EMBase, SPORTDiscus, Cochrane library (Controlled trials, Systematic reviews), and five trial registries. Two independent reviewers screened studies at title, abstract and full text. Following screening, data were extracted and charted, and presented as figures and tables alongside a narrative synthesis. Any study design conducted on adults, investigating the effects of IFRT for tendinopathy were included. Data were extracted on intervention parameters and outcomes of IFRT interventions.

Results

Four studies on patellar tendinopathy were included. A variety of outcomes were assessed, including pain, function, strength, power, and tendon morphological and mechanical properties, particularly changes in tendon thickness. IFRT intervention parameters were largely homogenously prescribed, with slight variances.

Conclusion

Despite a paucity of studies to date on the effects of IFRT for treating tendinopathy, preliminary evidence for beneficial effects of IFRT on clinical outcomes in patellar tendinopathy is encouraging. As IFRT is a relatively new and unexplored method in tendinopathy rehabilitation, definitive conclusions, and recommendations cannot be made at present, which should be addressed in future research, due to the potential therapeutic benefits highlighted in this review.

Lower-Limb Muscle Activity During Aquatic Treadmill Running in Individuals With Anterior Cruciate Ligament Reconstruction

INTRODUCTION

While anterior cruciate ligament (ACL) tears are commonly managed with ACL reconstruction (ACL-R), 35% of ACL-R individuals fail to return to the preinjury elite sport level. Persistent neuromuscular deficits in the hamstrings and quadriceps have been observed. It has been proposed that aquatic therapy can be used to optimize neuromuscular control after ACL-R.

OBJECTIVES

(1) To compare muscle activity in ACL-R individuals during aquatic treadmill (ATM) running at different water depths and (2) to compare muscle activity during ATM running between ACL-R and healthy individuals.

METHODS

A total of 38 participants, including 18 ACL-R individuals (mean postoperative time [SD] = 25.8 [25.0] mo) and 20 healthy individuals were recruited. Muscle activity of biceps femoris (BF), rectus femoris (RF), tibialis anterior, and medial gastrocnemius during land treadmill and ATM running at mid-shin, mid-thigh, and waist levels were recorded using surface electromyography (sEMG).  The sEMG signals of the selected muscles were normalized and expressed in % Maximal Voluntary Contraction (%MVC). Muscle activity of the ACL-R, ACL-contralateral, and healthy control limbs at different water depths was compared.

RESULTS

Among the 3 groups, the ACL-R group demonstrated the most prominent percentage increase of 101.97% (P = .001) at mid-shin level, 139.66% (P = .001) at mid-thigh level, and 141.97% (P < .001) at waist level, respectively, in %MVC when compared to land. In the ACL-R group, muscle activity of BF in the stance phase (BFSt) was significantly higher than the control group on land at all water depths. Muscle activity of RF in the swing phase (RFSw) in the ACL-R group significantly increased in all water depths immersion when compared to land, respectively.

CONCLUSION

This study showed an increasing trend in muscle activity of BFSt and RFSw in ACL-R individuals during ATM running at increased water depths. ATM running could be implemented as neuromuscular training in rehabilitation after ACL-R.

Characteristics of Complex Systems in Sports Injury Rehabilitation: Examples and Implications for Practice

Complex systems are open systems consisting of many components that can interact among themselves and the environment. New forms of behaviours and patterns often emerge as a result. There is a growing recognition that most sporting environments are complex adaptive systems. This acknowledgement extends to sports injury and is reflected in the individual responses of athletes to both injury and rehabilitation protocols. Consequently, practitioners involved in return to sport decision making (RTS) are encouraged to view return to sport decisions through the complex systems lens to improve decision-making in rehabilitation. It is important to clarify the characteristics of this theoretical framework and provide concrete examples to which practitioners can easily relate. This review builds on previous literature by providing an overview of the hallmark features of complex systems and their relevance to RTS research and daily practice. An example of how characteristics of complex systems are exhibited is provided through a case of anterior cruciate ligament injury rehabilitation. Alternative forms of scientific inquiry, such as the use of computational and simulation-based techniques, are also discussed-to move the complex systems approach from the theoretical to the practical level.

Electromyographic examination of knee training using a hybrid assistive limb after anterior cruciate ligament reconstruction: A case report

Muscle co-contraction can result in higher joint contact forces, compromising knee joint mobility for stability, thus leading to impaired lower extremity neuromuscular control, delayed return to sports, and increased incidence of secondary anterior cruciate ligament (ACL) injury post-ACL reconstruction. Hybrid assistive limb (HAL) training has the potential to correct impairment of antagonistic or synergistic muscle movement of the knee joint through bioelectric signal feedback from muscle signals with computer processing. We considered that HAL training would contribute to improve peak muscle torque through coordinating or decreasing higher levels of muscle co-contractions and reducing differences between hamstring and quadriceps muscle activity on electromyography (EMG). While playing handball, a 20-year-old female injured her ACL upon landing on one leg. Two months post-injury, she underwent arthroscopic, anatomic single-bundle ACL reconstruction with a semitendinosus tendon autograft. At a 4-month follow-up, she underwent knee HAL training, which was performed once a week for three sessions. EMG data were collected during the evaluations of pre- and post-HAL training. The average muscle amplitude was used to calculate the difference between vastus lateralis (VL) and semitendinosus (ST) muscles, and the muscle co-contraction index (CCI). The CCI reflects the simultaneous activation of antagonistic muscles, which is determined for knee extensor-flexor muscle pairs. Post-knee HAL training, the CCI of the lateral hamstring and quadriceps muscles during extension was lower than that during pre-HAL training in all sessions. However, no differences were found in the CCI for the medial hamstring and quadriceps muscles during extension and flexion pre- and post-knee HAL training. For post-knee HAL training, the difference between VL and ST EMG data during a closed-chain squat was lower than that during pre-HAL training in all sessions. Knee HAL training contributed to improved peak muscle torque through coordinating or decreasing higher levels of muscle co-contractions, and it reduced differences between hamstring and quadriceps muscle activity in the ACL reconstructed leg as depicted by EMG.

Acceleration Profiles and the Isoinertial Squatting Exercise: Is There a Direct Effect on Concentric-Eccentric Force, Power, and Neuromuscular Efficiency?

OBJECTIVE

To examine the selective influences of distinct acceleration profiles on the neuromuscular efficiency, force, and power during concentric and eccentric phases of isoinertial squatting exercise.

DESIGN

Cross-sectional study.

SETTING

Biomechanics laboratory of the university.

PARTICIPANTS

A total of 38 active adults were divided according to their acceleration profiles: higher (n = 17; >2.5 m/s2) and lower acceleration group (n = 21; <2.5 m/s2).

INTERVENTION

All subjects performed squats until failure attached to an isoinertial conic pulley device monitored by surface electromyography of rectus femoris, vastus medialis, vastus lateralis, biceps femoris, and semitendinosus.

MAIN OUTCOME MEASURES

An incremental optical encoder was used to assess maximal and mean power and force during concentric and eccentric phases. The neuromuscular efficiency was calculated using the mean force and the electromyographic linear envelope.

RESULTS

Between-group differences were observed for the maximal and mean force (Prange = .001-.005), power (P = .001), and neuromuscular efficiency (Prange = .001-.03) with higher significant values for the higher acceleration group in both concentric and eccentric phases.

CONCLUSION

Distinct acceleration profiles affect the neuromuscular efficiency, force, and power during concentric and eccentric phases of isoinertial squatting exercise. To ensure immediate higher levels of power and force output without depriving the neuromuscular system, acceleration profiles higher than 2.5 m/s2 are preferable. The acceleration profiles could be an alternative to evolve the isoinertial exercise.

Arthrogenic Muscle Inhibition: Best Evidence, Mechanisms, and Theory for Treating the Unseen in Clinical Rehabilitation

CONTEXT

Arthrogenic muscle inhibition (AMI) impedes the recovery of muscle function following joint injury, and in a broader sense, acts as a limiting factor in rehabilitation if left untreated. Despite a call to treat the underlying pathophysiology of muscle dysfunction more than three decades ago, the continued widespread observations of post-traumatic muscular impairments are concerning, and suggest that interventions for AMI are not being successfully integrated into clinical practice.

OBJECTIVES

To highlight the clinical relevance of AMI, provide updated evidence for the use of clinically accessible therapeutic adjuncts to treat AMI, and discuss the known or theoretical mechanisms for these interventions.

EVIDENCE ACQUISITION

PubMed and Web of Science electronic databases were searched for articles that investigated the effectiveness or efficacy of interventions to treat outcomes relevant to AMI.

EVIDENCE SYNTHESIS

122 articles that investigated an intervention used to treat AMI among individuals with pathology or simulated pathology were retrieved from 1986 to 2021. Additional articles among uninjured individuals were considered when discussing mechanisms of effect.

CONCLUSION

AMI contributes to the characteristic muscular impairments observed in patients recovering from joint injuries. If left unresolved, AMI impedes short-term recovery and threatens patients' long-term joint health and well-being. Growing evidence supports the use of neuromodulatory strategies to facilitate muscle recovery over the course of rehabilitation. Interventions should be individualized to meet the needs of the patient through shared clinician-patient decision-making. At a minimum, we propose to keep the treatment approach simple by attempting to resolve inflammation, pain, and effusion early following injury.

Contralateral strength training attenuates muscle performance loss following anterior cruciate ligament (ACL) reconstruction: a randomised-controlled trial

PURPOSE

To investigate the effects of cross-education (CE) exercise on strength and performance at 10 and 24 weeks post anterior cruciate ligament (ACL) surgery.

METHODS

Design: randomised controlled trial. N = 44 ACL-reconstruction patients, randomly-allocated into: CE: strength training of the non-operative limb, or CON: sham exercise of upper limb stretching. Each patient underwent standardised ACL rehabilitation, plus 8 weeks of thrice weekly CE or CON, commencing at 2 weeks post surgery. The primary outcome was quadriceps peak force (QPF) of the ACL-reconstructed limb at 10 weeks post surgery. Secondary measures were hamstrings peak force (HPF), rate of force development (RFD) and International Knee Documentation Committee score (IKDC) at 10 and 24 weeks; QPF and hop for distance (HOP) at 24 weeks post surgery.

RESULTS

CE significantly attenuated the decline in QPF of the ACL-reconstructed limb at 10 weeks compared to CON (16.6% decrease vs. 32.0%, respectively); that advantage was not retained at 24 weeks. A training effect was observed in the trained limb for HPF and QPF, which was retained at 24 weeks. No significant differences were observed for IKDC, HOP, RFD, or HPF of the reconstructed limb. Inter-limb symmetry (ILS) ranged from 0.78 to 0.89 and was not significantly different between groups.

CONCLUSION

High-intensity CE strength training attenuated the post-operative decline in QPF and should be considered in early-phase ACL rehabilitation. ILS data showed good symmetry, but it masked significantly inferior performance between groups and should be used with caution.

TRIAL REGISTRATION NUMBER

NCT02722876.

Rehabilitation after a Complete Avulsion of the Proximal Rectus Femoris Muscle: Considerations from a Case Report

BACKGROUND

A complete avulsion of the proximal rectus femoris muscle is a rare but severity injury. There is a lack of substantial information for its operative treatment and rehabilitation; in particular there is a lack of biomechanical data to evaluate long-term outcomes.

CASE PRESENTATION

The case report presents the injury mechanism and surgical treatment of a complete avulsion of the proximal rectus femoris muscle in a 41-year-old recreational endurance athlete. Moreover, within a one-year follow-up period, different biomechanical tests were performed to get more functional insights into changes in neuromuscular control, structural muscle characteristics, and endurance performance. Within the first month post-surgery, an almost total neuromuscular inhibition of the rectus femoris muscle was present. A stepwise reduction in inter-limb compensations was observable (e.g., in crank torque during cycling) during the rehabilitation. Muscular intra-limb compensations were shown at six months post-surgery and even one year after surgery, which were also represented in the long-term adaption of the muscle characteristics and leg volumes. A changed motor control strategy was shown by asymmetric muscle activation patterns during ergometer cycling, while the power output was almost symmetric. During rehabilitation, there might be a benefit to normalizing neuromuscular muscle activation in ergometer cycling using higher loads.

CONCLUSIONS

While the endurance performance recovered after six months, asymmetries in neuromuscular control and structural muscle characteristics indicate the long-term presence of inter- and intra-limb compensation strategies.

Hamstring Strain Injury (HSI) Prevention in Professional and Semi-Professional Football Teams: A Systematic Review and Meta-Analysis

Hamstring Strain Injuries (HSIs) are the most common type of lesion in professional footballers and the leading cause of absence days from sports. However, recent studies have shown that high-level football teams apparently do not apply any HSI prevention protocol. The aim of the study was to determine the effect of preventive strategies and protocols in reducing the incidence of hamstring muscle injuries in professional and semi-professional football teams. A literature search of PubMed/MEDLINE, ISI/Web of Science and Scopus databases was conducted with the keywords “hamstring* and (injury* or strain) and prevent* and (soccer or football)”. Quality and bias assessment was completed through the Kennelly modified scale. The Injury Incidence Rate (IIR) and the Incidence Rate Ratio (IRR) were assessed in the statistical analysis. In the meta-analysis, data were extracted, pooled and analysed with “Comprehensive Meta-Analysis Version 3.3.070” software. In total, 8 of the 1017 original search studies met the inclusion criteria of this review. The total exposure of the studies was 170,221.8 h, while the number of HSIs recorded was 165 in the intervention groups and 224 in the control groups. The average score of the quality assessment was 23.6/34. The meta-analysis of six of the eight included studies provided strong evidence that interventions are effective in reducing hamstring injuries. The IRR of the effect size was 0.443, with p-value = 0.001. The studies analysed applied different preventive strategies: the Nordic hamstring exercise, the FIFA 11+ programme and exercises for core stability or balance training. All these interventions proved to have a successful effect on prevention of hamstring injuries.

Effects of Hip Flexion on Knee Extension and Flexion Isokinetic Angle-Specific Torques and HQ-Ratios

Background and Methods

During isokinetic knee strength testing, the knee flexion angles that correspond to the measured torque values are rarely considered. Additionally, the hip flexion angle during seated testing diverges from that in the majority of daily life and sporting activities. Limited information concerning the influence of hip angle, muscle contraction mode, and velocity on the isokinetic knee strength over the entire range of motion (ROM) is available.

Twenty recreational athletes (10 females, 10 males; 23.3 ± 3.2 years; 72.1 ± 16.5 kg; 1.78 ± 0.07 m) were tested for isokinetic knee flexion and extension at 10° and 90° hip flexion with the following conditions: (i) concentric at 60°/s, (ii) concentric at 180°/s, and (iii) eccentric at 60°/s. The effects of hip angle, contraction mode, and velocity on angle-specific torques and HQ-ratios as well as conventional parameters (peak torques, angles at peak torque, and HQ-ratios) were analyzed using statistical parametric mapping and parametric ANOVAs, respectively.

Results

Generally, the angle-specific and conventional torques and HQ-ratios were lower in the extended hip compared to a flexed hip joint. Thereby, in comparison to the knee extension, the torque values decreased to a greater extent during knee flexion but not consistent over the entire ROM. The torque values were greater at the lower velocity and eccentric mode, but the influence of the velocity and contraction mode were lower at shorter and greater muscle lengths, respectively.

Conclusions

Isokinetic knee strength is influenced by the hip flexion angle. Therefore, a seated position during testing and training is questionable, because the hip joint is rarely flexed at 90° during daily life and sporting activities. Maximum knee strength is lower in supine position, which should be considered for training and testing. The angle-specific effects cannot be mirrored by the conventional parameters. Therefore, angle-specific analyses are recommended to obtain supplemental information and consequently to improve knee strength testing.

Preoperative exercise and outcomes after ventral hernia repair: Making the case for prehabilitation in ventral hernia patients

BACKGROUND

An increasing body of information suggests that preoperative physical activity level can impact postoperative outcomes. We sought to investigate this relationship in patients undergoing ventral hernia repair (VHR).

METHODS

The Abdominal Core Health Quality Collaborative registry was used to identify patients undergoing a VHR between 2013 and 2019. Patient-reported preoperative exercise level was used to stratify the study population into 4 groups: none (no reported exercise), sporadic (once a month), moderate (once per week), and intense (more than once per week). Multi-variate logistic regression analyses were used to assess the impact of preoperative exercise frequency on postoperative outcomes, including complications, hospital readmissions and length of stay. Changes in quality of life and pain from baseline to 30-days postoperatively were assessed using the Hernia-Related Quality of Life Survey and National Institutes of Health Patient-Reported Outcomes Measurement Information System 3A Pain Scale.

RESULTS

A total of 2,994 patients were included in the study, out of which 1,519 (50.7%) patients reported no preoperative exercise, 662 (22.1%) sporadic exercise, 467 (15.6%) moderate exercise, and 346 (11.6%) intense exercise. A total of 1,253 patients (19.2%) experienced a postoperative complication, out of which 249 (3.8%) had a surgical site infection. After multi-variable analysis and adjusting for demographics, comorbidities, and hernia characteristics, increasing exercise frequency (versus no reported exercise) was associated with significantly lower odds of experiencing any postoperative complication (sporadic: odds ratio 0.70; P = .008; moderate: odds ratio 0.62, P = .006; intense: odds ratio 0.67, P = .04), as well as lower odds of readmission (sporadic: odds ratio 0.04; moderate: odds ratio 0.40; intense: odds ratio 0.03; P = .01). Exercise level was not associated with length of stay (sporadic: P = .36; moderate: P = .19; intense: P = .95). No significant differences were found in changes in quality of life or pain from baseline to 30-days after surgery (Hernia-Related Quality of Life Survey, P = .24; National Institutes of Health Patient-Reported Outcomes Measurement Information System 3A P = .14).

CONCLUSION

Patients reporting greater exercise frequency before surgery demonstrated decreased risk of complications and readmission after undergoing ventral hernia repair. Increasing preoperative exercise participation through targeted prehabilitation programs may be a viable way for patients to reduce complications associated with VHR and improve their postoperative recovery.

Association between Kinesiophobia and Gait Asymmetry after ACL Reconstruction: Implications for Prevention of Reinjury

Gait asymmetries have been documented in individuals after anterior cruciate ligament (ACL) reconstruction (ACLR). The relationship between gait asymmetry and associated psychological factors, however, is not yet known. This study aimed to examine the relationship between kinesiophobia (fear of reinjury) and asymmetry of vertical ground reaction force (vGRF) and lower-extremity muscular activity in individuals after ACLR during gait. Twenty-eight males with a history of ACLR participated in the study. Force plate and surface electromyography was used to record peak vGRF and muscular activity. The Tampa Scale of Kinesiophobia (TSK-11) was used to measure kinesiophobia. Spearman’s rank correlations analysis was used to examine the relationship between TSK-11 scores and both gait asymmetry variables. There was a significant positive relationship between TSK-11 and asymmetry of the second peak of vGRF (r_s = 0.531, p = 0.002). In addition, there was a significant positive association between asymmetry of rectus femoris activity (r_s = 0.460, p = 0.007) and biceps femoris activity (r_s = 0.429, p = 0.011) in the contact phase. Results revealed a significant relationship between kinesiophobia and asymmetry in muscle activity and vGRF in different phases of the gait cycle. Interventions addressing kinesiophobia early in the rehabilitation after ACLR may support the restoration of gait symmetry, facilitate a more rapid return to sport, and reduce the risk of ACL reinjury.

A Randomized Controlled Trial of Eccentric Versus Concentric Cycling for Anterior Cruciate Ligament Reconstruction Rehabilitation

BACKGROUND

Persistent strength and biomechanical deviations remain after anterior cruciate ligament reconstruction (ACLR). Eccentric training may reduce these and associated reinjury or osteoarthritis risks.

HYPOTHESIS

For male patients who have undergone ACLR, eccentric training is more effective than concentric training at improving knee flexion angle and other biomechanical deviations, as well as strength and patient-reported outcomes, using a matched perceived exertion dose.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 26 men, 10-16 weeks after hamstring tendon graft ACLR, were randomized to an eccentric training group or a concentric control group. Both groups trained 3 times a week for 8 weeks using the same isokinetic cycle ergometer in a matched studio environment. Exercise dose was matched in training frequency, time, progression, and intensity using a target rating of perceived exertion. Baseline and follow-up testing included questionnaires, dynamometer strength testing, and walk/run gait analysis.

RESULTS

Eccentric training increased knee (+2.1°; P = .022) and hip (+2.1°; P = .010) flexion angles more than concentric training but not more than the minimal clinically important difference of 3°. Very large asymmetries in baseline knee abduction moment (walk, -0.10 N·m/kg/m; run, -0.54 N·m/kg/m) had not changed in either group by follow-up. Knee valgus angle effects were mixed. Tibial rotation angle increased in both groups, but concentric training was more effective at promoting symmetry (P < .001). Both groups had similar increases in affected limb quadriceps strength and knee flexion moments during walk/run gait (by 20% to 33%). Hamstring strength increased in the eccentric group (+15.4%) but not the concentric group. Eccentric group limb forces were 33% to 70% higher than those of the concentric group, with a lower heart rate. Both groups had low pain scores throughout.

CONCLUSION

For rehabilitation after ACLR, progressive eccentric cycle training was not more clinically effective than concentric training at a matched perceived intensity dose in male patients. This can guide exercise prescription for reducing gait and strength deviations of these patients.

REGISTRATION

PACTR201602001449365 (Pan African Clinical Trials Registry), NHREC 4344 (South African).

Concurrent Continuous Versus Bandwidth Visual Feedback With Varying Body Representation for the 2-Legged Squat Exercise

CONTEXT

Continuous visual feedback (VF) can improve abilities to achieve desired movements and maximize rehabilitation outcomes by displaying actual versus target body positions in real time. Bandwidth VF reduces the reliance on feedback by displaying movement cues only when performance errors exceed specified thresholds. As such, bandwidth VF may better train independent movement abilities through greater development of intrinsic body control. In this study, continuous and bandwidth VF were investigated across modes of display (abstract and representative) that differed in body-discernibility.

OBJECTIVE

To compare the performance of the 2-legged squat during training with concurrent feedback (real-time VF) and short-term retention (immediately after training, VF removed).

DESIGN

Cross-sectional.

SETTING

University research laboratory.

PARTICIPANTS

Eighteen healthy individuals.

METHODS

Marker-based motion capture displayed real-time position.

MAIN OUTCOME MEASURES

Four VF cases (continuous-abstract, bandwidth-abstract, continuous-representative, and bandwidth-representative) were evaluated for accuracy and consistency to a target trajectory and target depth.

RESULTS

During training, both continuous VF cases showed significantly (P < .05) higher accuracy and consistency to the target trajectory compared with both bandwidth VF cases. Bandwidth VF resulted in greater potential learning (retention performance relative to a training baseline) compared with continuous-abstract.

CONCLUSIONS

Continuous-representative may offer unique performance benefits in both training and retention of multisegment movement tasks. Bandwidth VF showed greater potential for learning. For long-term learning, an optimal VF paradigm should consider continuous-representative with bandwidth features.

Quadriceps Strength Symmetry Does Not Modify Gait Mechanics After Anterior Cruciate Ligament Reconstruction, Rehabilitation, and Return-to-Sport Training

BACKGROUND

After anterior cruciate ligament (ACL) reconstruction (ACLR), biomechanical asymmetries during gait are highly prevalent, persistent, and linked to posttraumatic knee osteoarthritis. Quadriceps strength is an important clinical measure associated with preoperative gait asymmetries and postoperative function and is a primary criterion for return-to-sport clearance. Evidence relating symmetry in quadriceps strength with gait biomechanics is limited to preoperative and early rehabilitation time points before return-to-sport training.

PURPOSE/HYPOTHESIS

The purpose was to determine the relationship between symmetry in isometric quadriceps strength and gait biomechanics after return-to-sport training in athletes after ACLR. We hypothesized that as quadriceps strength symmetry increases, athletes will demonstrate more symmetric knee joint biomechanics, including tibiofemoral joint loading during gait.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Of 79 athletes enrolled in the ACL-SPORTS Trial, 76 were participants in this study after completing postoperative rehabilitation and 10 return-to-sport training sessions (mean ± SD, 7.1 ± 2.0 months after ACLR). All participants completed biomechanical walking gait analysis and isometric quadriceps strength assessment using an electromechanical dynamometer. Quadriceps strength was calculated using a limb symmetry index (involved limb value / uninvolved limb value × 100). The biomechanical variables of interest included peak knee flexion angle, peak knee internal extension moment, sagittal plane knee excursion at weight acceptance and midstance, quadriceps muscle force at peak knee flexion angle, and peak medial compartment contact force. Spearman rank correlation (ρ) coefficients were used to determine the relationship between limb symmetry indexes in quadriceps strength and each biomechanical variable; alpha was set to .05.

RESULTS

Of the 76 participants, 27 (35%) demonstrated asymmetries in quadriceps strength, defined by quadriceps strength symmetry <90% (n = 23) or >110% (n = 4) (range, 56.9%-131.7%). For the biomechanical variables of interest, 67% demonstrated asymmetry in peak knee flexion angle; 68% and 83% in knee excursion during weight acceptance and midstance, respectively; 74% in internal peak knee extension moment; 57% in medial compartment contact force; and 74% in quadriceps muscle force. There were no significant correlations between quadriceps strength index and limb symmetry indexes for any biomechanical variable after return-to-sport training (P > .129).

CONCLUSION

Among those who completed return-to-sport training after ACLR, subsequent quadriceps strength symmetry was not correlated with the persistent asymmetries in gait biomechanics. After a threshold of quadriceps strength is reached, restoring strength alone may not ameliorate gait asymmetries, and current clinical interventions and return-to-sport training may not adequately target gait.

Rehabilitation training using a single-joint type hybrid assistive limb for the knee after anterior cruciate ligament reconstruction: an initial case report indicating safety and feasibility

[Purpose] The aim of this report was to describe the safety, feasibility, and efficacy of rehabilitation by knee extension and flexion training using the knee single-joint hybrid assistive limb in a patient after anterior cruciate ligament reconstruction. [Participant and Methods] A 33 year-old male underwent an arthroscopic procedure for anatomic single-bundle anterior cruciate ligament reconstruction with a semitendinosus tendon autograft. Rehabilitation training using the knee single-joint hybrid assistive limb was initiated at postoperative week 18 and repeated weekly for 3 weeks. The patient performed five sets of the knee single-joint hybrid assistive limb-assisted knee-extension-flexion exercises per session at a frequency of 10 exercises/set. [Results] The peak extension torque at all velocities with the limb symmetry index was higher after the hybrid assistive limb intervention (post-intervention) than before using it (pre-intervention). Peak flexion torques at 60°/s and 300°/s of limb symmetry index were higher post-intervention than pre-intervention. The range of motion in extension and flexion improved from −2° (pre-intervention) to −1° (post-intervention) and from 124° to 133°, respectively. The Lysholm score increased from 58 (pre-intervention) to 94 (post-intervention). [Conclusion] The knee single-joint hybrid assistive limb can be used safely for anterior cruciate ligament reconstruction training, without any adverse events. Our results indicate that the knee single-joint hybrid assistive limb training may improve muscle function, effectively overcoming dysfunction.

Function of the Distal Part of the Vastus Medialis Muscle as a Generator of Knee Extension Twitch Torque

The distal part of the vastus medialis (VM) (VM obliquus: VMO) muscle acts as the medial stabilizer of the patella. However, it has been known to facilitate VMO contraction during training of the quadriceps femoris muscle in knee joint rehabilitation. This study aimed to examine the contribution degree of VMO as a knee joint extension torque generator. Sixteen healthy male volunteers participated in this study. Electrical muscle stimulation (EMS) was performed on VMO at 60° knee angle for 20 min to induce muscle fatigue. Knee extension twitch torques (TT) at 90° and 30° knee angle evoked by femoral nerve stimulation were measured before and after EMS. Although each TT at 90° and 30° knee angle significantly decreased after EMS, the decreased TT rate in both joint angles showed no significant difference. Our results show that VMO might contribute to the generation of the knee joint torque at the same level in the range from flexion to extension. Therefore, it was suggested that the facilitating the neural drive for VMO is important during the quadriceps femoris muscle strengthening exercise.

Evolution of service metrics and utilisation of objective discharge criteria in anterior cruciate ligament reconstruction rehabilitation: a retrospective cohort study with historical control in a public hospital physiotherapy department

Background

ACL reconstruction (ACLR) is a common procedure requiring rehabilitation in public hospital physiotherapy departments. The rate of re-rupture and reduced rates of return to sport following ACLR are concerning. Current guidelines recommend a progressive approach to rehabilitation based on objective criteria. The aim of this study was to determine whether a new public hospital model of care incorporating a phase-based program increased physiotherapist utilisation of objective outcome measures, improved service metrics including attendance and rehabilitation completion rates, and increased patient-reported activity and knee function.

Methods

Records from patients attending outpatient physiotherapy after ACL reconstruction (N = 132) were included in a retrospective chart review to assess utilisation of objective measures such as quadricep and hamstring strength assessment, patient attendance and rehabilitation completion. Phone followup (minimum 1 year) was conducted to retrieve patient-reported measures of knee function (IKDC) and activity (Tegner Activity Scale). Patients were categorised by rehabilitation model of care (contemporary - time based [N = 93] vs new - phase based [N = 39]) and logistic regression used to assess the influence of patient factors and model of care on outcomes.

Results

Compliance was equivalent between models of care and completion rates (formal discharge by therapist) were low (30–38%). The probability of a patient receiving objective strength assessment was associated with model of care, sex, BMI and number of sessions attended. The probability of a patient being recorded as discharged from the program was significantly associated with model of care, and duration and number of sessions.

Conclusion

Introduction of an updated model of care including a phase-based rehabilitation program increased physiotherapist utilisation of objective outcome measures in line with current ACLR rehabilitation recommendations, increased total rehabilitation duration and increased total number of sessions attended. Despite this, rehabilitation completion rates remained low, and self-reported activity and knee function remained equivalent.

Level of evidence

III, retrospective cohort study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-020-00093-9.

Patient function in serial assessments throughout the post-ACL reconstruction progression

OBJECTIVE

To assess the changes in patient strength and function from 4- to 6-month assessments following ACLR, determine relationships between changes in strength to changes in subjective function, and identify factors that predict patients that fail to increase in strength.

DESIGN

Prospective, Cohort Study.

SETTING

Controlled Laboratory.

PARTICIPANTS

Forty-seven patients(27 female, 24.3 ± 11.1 years) completed a battery of performance assessments at approximately 4- and 6-months following primary ACLR (4.03 ±0 .49 and 6.46 ±0 .68 months).

MAIN OUTCOME MEASURES

Subjective scores and isokinetic knee flexor and extensor strength were compared across visits. Patients were categorized per their ability to increase in strength beyond a previously defined threshold(0.22 Nm/kg). Binary logistic regression models were used to determine predictors of patients that failed to meet strength changes.

RESULTS

Patients demonstrated improvements in patient-reported outcomes and strength measures between visits(P's < 0.05). Higher age (B = -0.073, P = .039), lower pre-injury activity levels (B = 0.61, P = .022), and higher limb symmetry indexes (B = -0.044, P = .05) at 4-months were predictors of patients that did not achieve improvements in quadriceps strength between assessments.

CONCLUSIONS

From 4- to 6-months post-ACLR, increases in subjective function, strength and symmetry were observed. High quadriceps symmetry at interim assessments without consideration of the magnitude of strength values could overestimate recovery of quadriceps function.

Examination of Corticospinal and Spinal Reflexive Excitability During the Course of Postoperative Rehabilitation After Anterior Cruciate Ligament Reconstruction

OBJECTIVE

To investigate corticospinal and spinal reflexive excitability and quadriceps strength in healthy athletes and athletes after anterior cruciate ligament reconstruction (ACLR) over the course of rehabilitation.

DESIGN

Prospective cohort study.

METHODS

Eighteen athletes with ACLR and 18 healthy athletes, matched by sex, age, and activity, were tested at (1) 2 weeks after surgery, (2) the "quiet knee" time point, defined as full range of motion and minimal effusion, and (3) return to running, defined as achieving a quadriceps index of 80% or greater. We measured (1) corticospinal excitability, using resting motor threshold (RMT) and motor-evoked potential amplitude at a stimulator intensity of 120% of RMT (MEP₁₂₀) to the vastus medialis, (2) spinal reflexive excitability, calculating the ratio of the maximal Hoffmann reflex to the maximal M-wave to the vastus medialis, and (3) isometric quadriceps strength.

RESULTS

The ACLR group had higher RMTs in the nonsurgical limb and higher MEP₁₂₀ in the surgical limb at all time points. The healthy-athlete group did not have interlimb differences. The RMT was positively associated with quadriceps strength 2 weeks after surgery; MEP₁₂₀ was associated with quadriceps strength at all time points.

CONCLUSION

Compared to healthy athletes, athletes after ACLR had altered corticospinal excitability that did not change from 2 weeks after surgery to the time of return to running. J Orthop Sports Phys Ther 2020;50(9):516-522. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9329.

A Secondary Injury Prevention Program May Decrease Contralateral Anterior Cruciate Ligament Injuries in Female Athletes: 2-Year Injury Rates in the ACL-SPORTS Randomized Controlled Trial

OBJECTIVE

To determine whether the addition of perturbation training to a secondary injury prevention program reduces the rate of second anterior cruciate ligament (ACL) injury compared to the prevention program alone.

DESIGN

Single-blinded randomized controlled trial.

METHODS

Thirty-nine female athletes who intended to return to cutting/pivoting sports were enrolled 3 to 9 months after primary anterior cruciate ligament reconstruction (ACLR). Athletes were randomized to receive a training program of either progressive strengthening, agility, plyometrics, and prevention (SAPP) (n = 20) or SAPP plus perturbation training (n = 19); each had 10 sessions over 5 weeks. Occurrence and side of second ACL injury were recorded for 2 years after primary ACLR.

RESULTS

There were 9 second ACL injuries in the 2 years after ACLR. There was no statistically significant difference in rate or side of second ACL injury between the SAPP-plus-perturbation training and SAPP groups.

CONCLUSION

Adding perturbation training to a secondary ACL injury prevention program did not affect the rate of second ACL injury in female athletes. J Orthop Sports Phys Ther 2020;50(9):523-530. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9407.

Effect of Adductor Canal Block Versus Femoral Nerve Block on Quadriceps Strength, Function, and Postoperative Pain After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Level 1 Studies

BACKGROUND

Femoral nerve block (FNB) is a popular technique for reducing postoperative pain in patients with anterior cruciate ligament reconstruction (ACLR), but it is also linked to a number of adverse effects, such as quadriceps weakness, antalgic ambulation, and increased fall risk. Adductor canal block (ACB) has been offered as a motor nerve-sparing alternative to FNB.

PURPOSE

To evaluate available literature that compares the effects of ACB and FNB on functional outcomes after arthroscopic ACLR.

STUDY DESIGN

Systematic review.

METHODS

Following the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a search of PubMed (Ovid), CINAHL, Scopus, Cochrane, and Google Scholar databases was conducted. Search terms were designed to capture studies comparing the effects of ACB and FNB in patients undergoing arthroscopic ACLR. Data were evaluated regarding study and patient characteristics, functional measures, opioid consumption, pain scores, and complications.

RESULTS

Eight randomized controlled trials (N = 655 patients) comparing the efficacy of ACB versus FNB in arthroscopic ACLR were included. The heterogeneity of outcome measures precluded meta-analysis. Seven studies reported functional measures, which included isokinetic strength, straight-leg raise, and other various measures. Follow-up periods varied between 1 hour and 6 months. In 3 trials, ACB was found to preserve quadriceps strength as measured using straight-leg raise for the first 12 to 24 hours after surgery, while 3 other trials found no difference between the groups. No differences were reported in isokinetic strength at 6 months. In other functional measures, ACB either outperformed or was equivalent to FNB. The majority of studies reporting opioid consumption, pain scores, and complications found no differences between the blocks.

CONCLUSION

This systematic review suggests that when compared with FNB, ACB preserves quadriceps function in the early postoperative period after ACLR while providing a similar level of analgesia. Limitations of this study include the use of various functional measures and limited long-term follow-up. More research evaluating long-term functional outcomes with standardized measures is needed to draw adequate conclusions regarding the effects of ACB and FNB on function after ACLR.

Quadriceps muscle compensatory activations are delayed following anterior cruciate ligament reconstruction using hamstring tendon graft

BACKGROUND

Compensatory and anticipatory quadriceps activation (CQA and AQA) in response to postural perturbations are essential for functional stability of the knee. This study aimed at investigating CQA and AQA before and after anterior cruciate ligament reconstruction (ACLR) using hamstrings graft.

METHODS

Twelve participants with ACLR and 12 healthy controls were exposed to 10 either unpredictable or predictable perturbations of the knee before ACLR (T1), two months (T2) and six months (T3) after surgery. Latencies of CQA and AQA in vastus lateralis (VL), rectus femoris (RF) and vastus medialis (VM) were measured.

RESULTS

Latency of CQA was delayed in ACLR compared to controls at T1 for VL (105 ± 25 vs. 57 ± 9 ms; P < .001), RF (102 ± 23 vs. 56 ± 9 ms; P < .001) and VM (107 ± 24 vs. 66 ± 16 ms; P < .001), at T2 for VL (68 ± 14 vs. 55 ± 10 ms; P < .01) and at T3 for VL (105 ± 22 vs. 58 ± 7 ms; P < .001), RF (102 ± 22 vs. 58 ± 12 ms; P < .001) and VM (106 ± 20 vs. 63 ± 8 ms; P < .001). AQA occurred earlier in ACLR than in controls at T1 for VL (-82 ± 64 vs. -14 ± 11 ms; P < .05) and VM (-105 ± 68 vs. -9 ± 12 ms; P < .05).

CONCLUSION

CQA are delayed following ACLR with hamstring graft and should be addressd by post-surgical rehabilitation.

How Much Time Is Needed Between Serial "Return to Play" Assessments to Achieve Clinically Important Strength Gains in Patients Recovering From Anterior Cruciate Ligament Reconstruction?

BACKGROUND

Pass rates for return-to-play evaluations are alarmingly low for patients after anterior cruciate ligament reconstruction (ACLR). Since timing of return to play is a complicated decision, it is important that patients be given optimal time to realize meaningful improvements in strength that warrant additional testing.

PURPOSE

To (1) compare outcomes among patients assessed at different time points after ACLR, (2) determine strength gains indicative of improvements in subjective function, and (3) determine the amount of time necessary to achieve meaningful strength gains.

STUDY DESIGN

Cross-sectional/case-control study; Level of evidence, 3.

METHODS

A total of 293 patients participated in the study after ACLR (mean ± SD, 23.2 ± 10.1 years old; n = 142 female participants; 6.4 ± 0.9 months after ACLR). Participants were stratified on the month of their evaluation after ACLR: 5 to 6 months (n = 122), 6 to 7 months (n = 102), 7 to 8 months (n = 43), and 8 to 9 months (n = 26). The International Knee Documentation Committee (IKDC) subjective form and knee extensor and flexor torque and symmetry, as assessed through an isokinetic dynamometer, were compared among groups. Forty patients (20 female participants, 20.4 ± 7.1 years old) were referred for subsequent testing (2.14 ± 0.78 months after initial visit). Subjective improvement between visits was defined as a ≥9-point change of the IKDC score. Thresholds of knee extensor torque and symmetry indicative of subjective improvement and the time between assessments needed to achieve these strength improvements were determined.

RESULTS

Patients between 5 and 6 months (IKDC, 79.7; interquartile range [IQR], 70.1-88.5) had lower subjective function compared to patients between 6 and 7 months (IKDC, 83.9; IQR, 74.5-92.0; P = .019) and 8 and 9 months after ACLR (IKDC, 89.1; IQR 75.8-92.3; P = .026). Patients between 5 and 6 months (1.41 N·m/kg; IQR, 1.16-1.73 N·m/kg]) had lower knee extensor torque compared to patients 6 and 7 months (1.59 N·m/kg; IQR, 1.23-1.95 N·m/kg; P = .013) and 7 and 8 months after ACLR (1.62 N·m/kg; IQR, 1.30-1.86 N·m/kg; P = .046). Patients between 5 and 6 months (66.4%; IQR, 54.2-78.6) had lower symmetry compared to patients between 6 and 7 months (71.8%; IQR,61.1-82.9; P = .019) and 8 and 9 months afterACLR (75.2%; IQR, 66.6-87.7; P = .014). Of the 40 patients that completed follow-up assessments, an increase in knee extensor torque of 0.22 N·m/kg and symmetry of 5.75% discriminated patients that achieved subjective improvement. A period of 1.97 months between assessments discriminated those that achieved the established symmetry threshold.

CONCLUSION

Patients demonstrate increasing subjective and quadriceps function when tested at later time points from surgery; however, the observed values are low, suggesting that at 9 months patients are demonstrating deficits that may be improving. Approximately 2 months is needed to observe clinically meaningful improvements.

Effects on Lower Extremity Neuromuscular Control Exercises on Knee Proprioception, Muscle Strength, and Functional Level in Patients with ACL Reconstruction

Objective

The purpose of this study was to determine the effects of lower extremity motor control exercises on knee proprioception, muscle strength, and functional level in patients with anterior cruciate ligament reconstruction (ACL-R).

Materials and Methods

Thirty-two of the 57 patients with ACL-R using tibialis anterior allografts were divided into two groups. Group I: lower extremity motor control exercises were added to the standard rehabilitation program. Group II: standard rehabilitation program was applied. Effects of lower extremity motor control exercises on quadriceps and hamstring muscles strength, knee joint position sense, and hop test were evaluated.

Results

There were no differences in muscle strength and endurance of the quadriceps and hamstring between the operative and nonoperative sides in Group I (p > 0.05) while there were significant differences in strength of the quadriceps and hamstring between the operative and nonoperative sides in Group II (p < 0.05). There were significant differences in the endurance of the quadriceps and hamstring and knee joint position sense at 15°, 45°, and 75° between the operative sides of the patients in both groups (p < 0.05).

Conclusions

The neuromuscular control exercises program was found to be more effective in reducing the difference in strength while the standard program was found to be more effective in reducing the difference in endurance between the operated knee and the other knee. This study revealed that neuromuscular control exercises should also be used to improve knee proprioception sense following ACL-R.

Functional electrical stimulation following anterior cruciate ligament reconstruction: a randomized controlled pilot study

Background

Inadequate quadriceps strength following anterior cruciate ligament reconstruction (ACLR) often results in alterations in gait pattern that are usually reported during loading response. Neuro-muscular electrical stimulation (NMES) is frequently used to overcome this quadriceps weakness. Despite the beneficial effects of NMES, persistent deficits in strength and gait are reported. The aim of this study was to investigate the feasibility of applying quadriceps functional electrical stimulation (FES) during walking in addition to standard rehabilitation, in the initial stage of ACLR rehabilitation.

Methods

Subjects were randomized to quadriceps FES synchronized with walking group (n = 10) or quadriceps NMES (duty cycle of 10 s on/10 s off) group (n = 13). Both interventions were performed for 10 min three days a week, in addition to a standard rehabilitation program. Assessments were performed up to 2 weeks before the ACLR (pre-ACLR), and 4 weeks postoperatively. Outcomes measured were gait speed, single limb stance gait symmetry, quadriceps isometric peak strength ratio (peak strength at 4 weeks/peak strength pre-ACLR) and peak strength inter-limb symmetry. Gait outcomes were also assessed 1-week post-surgery.

Results

Subjects in both groups regained pre-ACLR gait speed and symmetry after 4 weeks of rehabilitation, with no difference between groups. However, although pre-ACLR quadriceps peak strength was similar between groups (FES - 205 Nm, NMES − 225 Nm, p = 0.605), subjects in the FES group regained 82% of their pre-quadriceps strength compared to 47% in the NMES group (p = 0.02). In addition, after 4 weeks, the FES group had significantly better inter-limb strength symmetry 0.63 ± 0.15 vs. 0.39 ± 0.18 in the NMES group (p = 0.01).

Conclusions

Quadriceps FES combined with traditional rehabilitation is a feasible, early intervention treatment option, post-ACLR. Furthermore, at 4 weeks post-surgery, FES was more effective in recovering quadriceps muscle strength than was NMES. While spatiotemporal gait parameters did not differ between groups, kinetic and kinematic studies may be useful to further understand the effects of quadriceps FES post-ACLR. The promising results of this preliminary investigation suggest that such studies are warranted.

Trial registration

ISRCTN 02817399. First posted June 29, 2016.

Evaluation of the effect of cooling strategies on recovery after surgical intervention

Introduction

Different cooling strategies exist for emergency treatments immediately after sports trauma or after surgery. The aim of this study was to investigate the effects of three cooling regimen during the immediate postoperative phase as well as in the rehabilitation phase.

Methods

36 patients undergoing anterior cruciate ligament reconstruction received either no cooling (control-group, Con, N=12), were cooled with a menthol-containing cooling bandage (Mtl, N=12) or cooled with an ice containing cold pack (CP, N=12). During a 12-week physiotherapy treatment the cross section of the vastus medialis muscle was examined (day—1; 30; 60; 90) and painkiller consumption was documented.

Results

A significant reduction in the cross section area 30 days after surgery was observed in CP and Con (Mtl: −3.2±1.7%, p=0.14, CP: −8.8±4.3%, p<0.01, Con: −7.2±8.1%, p<0.05). After 90 days of therapy, a significant increase in muscle cross section area was observed in Mtl (Mtl: 4.6%±6.1%, p<0.05, CP: 1.9%± 8.1%, p=0.29, Con: 3.3%±9.4%, p=0.31). The absolute painkiller consumption was lower for Mtl (25.5±3.7 tablets) than for CP (39.5±6.9 tablets) or Con (34.8±4.2 tablets).

Conclusion

We observed a beneficial effect of cooling by a menthol-containing bandage during the rehabilitation phase. Reduction of muscle cross section within 30 days after surgery was prevented which highly contributed to rehabilitation success after 90 days of therapy. Painkiller consumption was reduced with Mtl.

Comparison of Short-term Biodex Results After Anatomic Anterior Cruciate Ligament Reconstruction Among 3 Autografts

Background:

An individualized approach to anterior cruciate ligament reconstruction (ACLR) typically includes criteria-based postoperative rehabilitation. However, recent literature has suggested residual quadriceps weakness up to 12 months after ACLR, especially with a quadriceps tendon (QT) autograft.

Hypothesis:

The QT would have poorer quadriceps strength symmetry at 5 to 8 months compared with the hamstring tendon (HS) and patellar tendon (BPTB), but there would be no significant difference at 9 to 15 months among all 3 groups.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent anatomic primary ACLR with an autograft were reviewed retrospectively. Isometric quadriceps and hamstring strength measurements were obtained clinically at 5 to 8 months and 9 to 15 months postoperatively. Return-to-running and return-to-play criteria included greater than 80% and 90% quadriceps strength symmetry, respectively.

Results:

A total of 73 patients with 5- to 8-month follow-up were identified, and 52 patients had 9- to 15-month data. The QT group had a significantly lower quadriceps index at 5 to 8 months (69.5 ± 17.4) compared with the BPTB (82.8 ± 14.6; P = .014) and the HS (86.0 ± 18.6; P = .001) groups. More patients with an BPTB autograft met criteria for return to running and return to play (60% and 47%, respectively) compared with the QT group (26% and 13%, respectively) at 5 to 8 months. Given the sample sizes available, we observed no significant difference in the quadriceps index and return-to-play and return-to-running criteria at 9 to 15 months among those undergoing ACLR with a QT, BPTB, or HS graft.

Conclusion:

Patients undergoing ACLR with a QT graft demonstrated clinically meaningful quadriceps asymmetry at 5 to 8 months and 9 to 15 months postoperatively. Additionally, fewer patients in the QT group met criteria for return to play and running at 5 to 8 months than the BPTB and HS groups. These data suggest that a longer time to return to play and specific rehabilitation protocols that emphasize quadriceps strengthening may be necessary because of residual quadriceps weakness after ACLR with a QT graft.

Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial

PURPOSE

The aim of this study was to investigate the effects of concentric and eccentric cross-education (CE) on quadriceps strength and knee function recoveries after anterior cruciate ligament (ACL) reconstruction.

METHODS

Forty-eight patients (age: 29.5 ± 6.8 years, body mass index: 26.1 ± 3.2 kg/m²) who had undergone ACL reconstruction with hamstring tendon autograft were included in the study. The patients were randomly divided into three groups when they reached four weeks post surgery: (1) concentric CE (n = 16); (2) eccentric CE (n = 16); and (3) control (n = 16). All groups followed the same post-surgical rehabilitation program for their reconstructed limb. Additionally, the two experimental groups followed eight weeks of isokinetic training for the uninjured knee at 60°/s for 3 days per week. Quadriceps maximum voluntary isometric strength (MVIC) was measured during the 4th week (pre-training), 12th week (post training), and 24th week post surgery. The single-leg hop distance and International Knee Documentary Committee (IKDC) scores were also evaluated during the 24th week post surgery. Analysis of variance was used for statistical analysis.

RESULTS

Group-by-time interaction was significant for quadriceps MVICs for reconstructed and healthy limbs (p = 0.02). Quadriceps strength of both knees was greater in concentric and eccentric CE groups compared to control group during the 12th- and 24th weeks post surgery (p < 0.05). Strength gain was 28% and 31% in concentric and eccentric CE groups, respectively, when compared with the control group. Concentric and eccentric CE had similar effects on quadriceps strength recovery (n.s.). IKDC score, and single-leg hop distances were not significantly different among groups (n.s.).

CONCLUSIONS

Concentric and eccentric quadricep strengthening of healthy limbs in early phases of ACL rehabilitation improved post-surgical quadriceps strength recovery of the reconstructed limb. CE should be integrated into ACL reconstruction rehabilitation, especially in the early rehabilitative phases to restore quadriceps strength.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Neuromuscular Electrical Stimulation Superimposed on Movement Early after ACL Surgery

PURPOSE

Quadriceps weakness and asymmetrical loading of lower limbs are two major issues after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to evaluate the effectiveness of a 6-wk training protocol involving neuromuscular electrical stimulations (NMES) of the quadriceps muscle superimposed on repeated sit-to-stand-to-sit exercises (STSTS), as an additional treatment to standard rehabilitation, from the 15th to the 60th day after ACLR.

METHODS

Sixty-three ACLR patients were randomly allocated to one of the three treatment groups: NMES superimposed on STSTS (NMES + STSTS), STSTS only, or no additional treatment (NAT) to standard rehabilitation. Maximal isometric strength of the knee extensor and flexor muscles was measured 60 and 180 d after surgery. Asymmetry in lower extremity loading was measured during a sit-to-stand movement at 15, 30, 60, and 180 d after surgery and during a countermovement jump 180 d after surgery by means of two adjacent force platforms placed under each foot.

RESULTS

The NMES + STSTS participants showed higher muscle strength of the knee extensors, which was accompanied by lower perception of pain and higher symmetry in lower extremity loading compared with STSTS-only and NAT participants after both 60 and 180 d from surgery. Participants in the STSTS-only treatment group showed higher symmetry in lower extremity loading compared with those in the NAT group 60 d after surgery.

CONCLUSIONS

These results suggest that an early intervention based on NMES superimposed to repeated STSTS exercises is effective for recovering quadriceps strength and symmetry in lower extremity loading by the time of return to sport.

Psychological Readiness to Return to Sport Is Associated With Knee Kinematic Asymmetry During Gait Following Anterior Cruciate Ligament Reconstruction

BACKGROUND

Gait asymmetry is frequently observed following anterior cruciate ligament reconstruction (ACLR). Psychological readiness to return to sport is associated with functional and activity-related outcomes after ACLR. However, the association between gait asymmetry and psychological readiness to return to sport is unknown.

OBJECTIVES

To determine the relationship between kinematic and kinetic measures of knee symmetry during gait and psychological readiness to return to sport following ACLR.

METHODS

In this controlled laboratory, cross-sectional study, 79 athletes (39 women) underwent gait analysis following impairment resolution after ACLR (ie, full range of motion, minimal or no effusion, quadriceps strength index of 80% or greater). Interlimb differences during gait were calculated for sagittal plane knee angles at initial contact, peak knee flexion, and peak knee extension, as well as for peak knee flexion moment and peak knee adduction moment. Athletes completed the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) to assess psychological readiness to return to sport. Pearson correlations were used to examine the association between ACL-RSI score and each gait symmetry variable.

RESULTS

Significant negative correlations were observed between the ACL-RSI and 2 kinematic variables: knee flexion angle at initial contact (r = -0.281, P = .012) and peak knee flexion (r = -0.248, P = .027). In general, lower scores on the ACL-RSI were associated with greater interlimb asymmetry.

CONCLUSION

There was a weak association between psychological readiness to return to sport and knee kinematic asymmetry during gait. J Orthop Sports Phys Ther 2018;48(12):968-973. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8084.

Effect of high body mass index on knee muscle strength and function after anterior cruciate ligament reconstruction using hamstring tendon autografts

BACKGROUND

Increased body mass index (BMI) has been associated with poorer function in patients who have undergone anterior cruciate ligament (ACL) reconstruction. However, the effect of high BMI on muscle strength in these patients remained unclear. The current study aimed to compare knee muscle strength and Knee injury and Osteoarthritis Outcome Score (KOOS) in ACL-reconstructed patients with a variety of different BMIs.

METHODS

From November 2013 to March 2016, we prospectively enrolled 30 patients who underwent ACL reconstruction (18-60 years of age). Anthropometric parameters, body compositions, isokinetic muscle strength and KOOS were assessed preoperatively, and at post-operative 16th week and 28th week. The patients were stratified into two groups by BMI, i.e. normal BMI (18.5-24.9 kg/m²) and high BMI (≥25.0 kg/m²).

RESULTS

Twelve patients in the normal BMI group completed the follow-up, while sixteen patients did so in the high BMI group. In comparison of muscle strength between baseline and 28th week follow-up, the normal BMI group had significant increases in overall knee muscle strength, while the high BMI group only had increases in extensors of uninjured knee and flexors of the injured knee. However, there were significant increases in all KOOS subscales for the high BMI group. The high BMI patients reported increased KOOS, which may reflect the contribution of ligament stability in the presence of inadequate muscle strength.

CONCLUSIONS

The normal BMI patients had improvement in all knee muscle strength following ACL reconstruction, while high BMI patients only had increases in certain knee muscles. High BMI patients had a decreased quadriceps muscle symmetry index, as compared to their normal BMI counterparts. Increases in quadriceps muscle strength of the uninjured knee and ACL reconstruction were associated with improvements in KOOS in high BMI patients.

Self-reported outcomes are associated with knee strength and functional symmetry in individuals who have undergone anterior cruciate ligament reconstruction with hamstring tendon autograft

BACKGROUND

The aim of this study was to investigate the relationship between self-reported knee outcomes and limb symmetry indices (LSIs) for hip and knee strength, postural control and single-leg hop distance in individuals who had undergone an anterior cruciate ligament (ACL) reconstruction via hamstring tendon autograft (HTG).

METHODS

A total of 72 participants with a history of unilateral ACL reconstruction via HTG (mean ± standard deviation (SD) age: 28.0 ± 7.6 years; height: 178.4 ± 6.7 cm; mass 76.9 ± 14.9 kg) were included. International Knee Documentation Committee 2000 Subjective Knee Form (IKDC), Lysholm, Knee Osteoarthritis Outcomes Scores (KOOS) and Tampa scores were used to evaluate self-reported outcomes. Concentric and eccentric knee extensor and flexor, and hip strength, postural control and single leg hop distance were evaluated for performance-based outcomes. The relationships between the LSI scores and the performance measures were explored using the Pearson correlation coefficient.

RESULTS

The IKDC, Lysholm and KOOS scores were positively correlated with knee extensor and flexor strength LSIs (P < 0.05, r = 0.34 to r = 0.50), and the Tampa score was negatively correlated with eccentric extensor LSI (P = 0.02, r = -0.34). Single-leg hop distance LSI was correlated with IKDC and Lysholm scores (P = 0.003, r = 0.50; P = 0.04, r = 0.29) respectively, while postural control was only correlated with the KOOS scores (P < 0.001, r = 0.51 to r = 0.52).

CONCLUSIONS

Compared to Lysholm and Tampa scores, KOOS and IKDC scores were more likely to be correlated with performance-based outcomes. Therefore, KOOS and IKDC scores may help clinicians in return to sport decision making when there is a limited time to perform extensive evaluations or access equipment.

Higher hamstring-to-quadriceps isokinetic strength ratio during the first post-operative months in patients with quadriceps tendon compared to hamstring tendon graft following ACL reconstruction

PURPOSE

The aim of this study was to compare isokinetic quadriceps and hamstring muscle strength in patients following anterior cruciate ligament (ACL) reconstruction who received either hamstring (HT) or quadriceps (QT) tendon autografts at two time intervals within the first year after surgery.

METHODS

One hundred twenty-four patients, 81 males (age 22.0 ± 6.2 years) and 43 females (age 20.9 ± 8.7 years), participated in this study. ACL reconstruction was performed with either quadriceps tendon autografts (QT; n = 61) or hamstring tendon autografts (HT; n = 63). Two isokinetic muscle strength tests (t1: 5.5 ± 1.2 months; t2: 7.6 ± 1.6 months) were performed at an angular velocity of 60°/s in both the injured and contralateral knees. An independent t test as well as a two-factor analysis of variance with repeated measurements was used. The significance level was set at p < 0.05.

RESULTS

A statistically significant lower knee extensor strength was observed in the QT group within one year after surgery (p < 0.001). Additionally, data showed a significant higher H/Q ratio in QT patients compared to the HT group at t1 (p < 0.001) and t2 (p = 0.001) as well as a significant effect over time (p < 0.001) and interaction effect of time and graft (p = 0.007). Side-to-side values for extensor muscle strength were significantly (p < 0.001) greater in HT graft patients, while QT patients showed significantly (p < 0.001) greater values for flexor muscle strength at both time points of isokinetic testing, respectively.

CONCLUSION

The results of this study indicate that graft choice has an impact on extensor strength in the first months after ACL reconstruction; however, there is no impact on flexor strength. The finding of a higher H/Q ratio in patients with QT grafts within the first months following surgery is possibly of clinical relevance. This may potentially be associated with lower stress on the maturing ACL graft. Furthermore, normal thigh strength can be restored over time.

LEVEL OF EVIDENCE

III.

Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to knee ligament sprain. J Orthop Sports Phys Ther. 2017;47(11):A1-A47. doi:10.2519/jospt.2017.0303.

Clinical course and recommendations for patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative review

Almost all athletes who have suffered an anterior cruciate ligament (ACL) injury expect a full return to sports at the same pre-injury level after ACL reconstruction (ACLR). Detailed patient information on the reasonable outcomes of the surgery may be essential to improve patient satisfaction.

Pre-operative rehabilitation before ACLR should be considered as an addition to the standard of care to maximise functional outcomes after ACLR.

We propose an optimised criterion-based rehabilitation programme within a biopsychosocial framework.

No benchmark exists for evaluating return-to-sport (RTS) readiness after ACLR. Therefore, the authors propose a multi-factorial RTS test battery. A combination of both physical and psychological elements should be included in the RTS test battery.

There is need for shared decision-making regarding RTS.

Cite this article: EFORT Open Rev 2017;2:410-420. DOI: 10.1302/2058-5241.2.170011