The relationship between knee muscle strength and knee biomechanics during running at 6 and 12 months after anterior cruciate ligament reconstruction

Rehabilitation and return-to-sport after anterior cruciate ligament injury and reconstruction: Exploring physical therapists' approaches in Argentina

OBJECTIVES

To investigate the current clinical practice regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional design. Online survey.

SETTING

Survey platform.

PARTICIPANTS

Argentinian physical therapists (PTs).

OUTCOME MEASURES

The survey consisted of a combination of 39 open- and closed-ended questions, divided across 3 sections: (1) demographic and professional information, (2) clinical practice and rehabilitation strategies, and (3) return-to-running (RTR) and RTS.

RESULTS

A total of 619 PTs completed the survey. Considerable variability was observed in preoperative rehabilitation, criteria used for rehabilitation progression and RTS decision-making criteria used by PTs. From the total surveyed, 336 (54.3%) carried out RTS assessment in their clinical practice. Most of PTs (53.3%) use visual estimation to assess knee range of motion. Only 20% of the PTs reported incorporating patient-reported outcome measures in their decision-making. From PTs who use strength assessment as a criterion of RTS (68.8%), 16.6% extrapolate this from jump tests and 15.3% use manual muscle testing. Less than the 50% of the PTs recommended nine months or more to allow patients to RTS.

CONCLUSIONS

Current rehabilitation practices of Argentinian PTs following ACLR are largely variable and not aligned with current evidence and scientific guidelines. To achieve better rehabilitation and RTS practices better knowledge dissemination and implementation are required.

The Risk Factors and Preventive Strategies of Poor Knee Functions and Osteoarthritis after Anterior Cruciate Ligament Reconstruction: A Narrative Review

Anterior cruciate ligament reconstruction (ACLR) is the standard surgical treatment for ACL injury, which typically uses a graft to replace the torn ligament in the knee that uses small incisions with minimally invasive surgery. The optimal knee functions following ACLR depend on rehabilitation processes before and after the surgery. Knee function is the ability of the knee to perform various types of functional movements like walking, squatting, running, jumping, and pivoting where patients expect to achieve maximum knee function or at least more than 80% of its initial condition before the injury to avoid being categorized as poor knee function after ACLR. Patients use patient-reported outcome measures to collect data on their health status and quality of life after ACLR. Post-traumatic osteoarthritis (PTOA) is a type of OA that manifests in local cartilage injury caused by chondrocyte death, and matrix dispersion occurs following a joint injury like ACL injury. Gender, time from injury to surgery, and graft type were considered as risk factors for poor knee function after ACLR, while overweight, meniscus tear, and cartilage defect as risk factors for PTOA. However, age is an internal risk factor for both poor knee function and PTOA following ACLR. This review suggests several strategies to prevent both conditions, including a pre-operative program, comprehensive rehabilitation, body weight control, and return to sport (RTS) consideration based on physical capacity, proper time, and psychological readiness.

Pain Early After Anterior Cruciate Ligament Reconstruction is Associated With 6-Month Loading Mechanics During Running

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) results in persistent altered knee biomechanics, but contributing factors such as pain or patient function, leading to the altered loading, are unknown.

HYPOTHESIS

Individuals with worse self-reported pain after ACLR would have poorer biomechanics during running, and poor loading mechanics would be present in the ACLR limb compared with contralateral and control limbs.

STUDY DESIGN

Cohort pilot study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 20 patients after ACLR (age, 18.4 ± 2.7 years; height, 1.7 ± 0.1 m; mass, 84.2 ± 19.4 kg) completed visual analog scale and Knee Injury and Osteoarthritis Outcomes Score (KOOS) at 1 and 6 months postsurgery. At 6 months postsurgery, patients underwent biomechanical testing during running. A total of 20 control individuals also completed running biomechanical analyses. Associations between patient outcomes and biomechanics were conducted, and differences in running biomechanics between groups were analyzed.

RESULTS

KOOS pain score 1 month after surgery was associated with peak ACLR knee abduction moment (R2 = 0.35;P = 0.01). At 6-months, KOOS sport score was related to peak abduction moment in the ACLR limb (R2 = 0.23; P = 0.05). For change scores, the improvement in pain scores related to ACLR limb peak knee abduction moment (R2 = 0.55; P = 0.001). The ACLR limb had lower knee excursion, extension moments, and ground-reaction forces compared with the uninvolved and control limb. The uninvolved limb also had higher ground-reaction forces compared with the ACLR limb and control limb.

CONCLUSION

These results suggest that patient-reported outcomes 1 and 6 months after surgery are associated with running mechanics 6 months after ACLR. Further, the underloading present in the ACLR limb and overloading in the uninvolved limb indicates greater need for running rehabilitation after ACLR.

CLINICAL RELEVANCE

Understanding pain and how it may be linked to movement dysfunction is important for improving long-term outcomes.

The Influence of Quadriceps Strength and Rate of Torque Development on the Recovery of Knee Biomechanics During Running After Anterior Cruciate Ligament Reconstruction

BACKGROUND

After anterior cruciate ligament reconstruction (ACLR), altered surgical knee biomechanics during running is common. Although greater quadriceps strength is associated with more symmetrical running knee kinetics after ACLR, abnormal running mechanics persist even after resolution of quadriceps strength deficits. As running is a submaximal effort task characterized by limited time to develop knee extensor torque, quadriceps rate of torque development (RTD) may be more closely associated with recovery of running knee mechanics than peak torque (PT).

PURPOSE

To assess the influence of recovery in quadriceps PT and RTD symmetry on knee kinematic and kinetic symmetry during running over the initial 2 years after ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 39 Division I collegiate athletes (106 testing sessions; 19 female) completed serial isometric performance testing and running analyses between 3 and 24 months after ACLR. Athletes performed maximal and rapid isometric knee extension efforts with each limb to assess PT and RTD between-limb symmetry indices (PTLSI and RTDLSI), respectively. Peak knee flexion difference (PKFDIFF) and peak knee extensor moment limb symmetry index (PKEMLSI) during running were computed. Multivariable linear mixed-effects models assessed the influence of PTLSI and RTDLSI on PKFDIFF and PKEMLSI over the initial 2 years after ACLR.

RESULTS

Significant main effects of RTDLSI (P < .001) and time (P≤ .02) but not PTLSI (P≥ .24) were observed for both PKFDIFF and PKEMLSI models. For a 10% increase in RTDLSI, while controlling for PTLSI and time, a 0.9° (95% CI, 0.5°-1.3°) reduction in PKFDIFF and a 3.5% (95% CI, 1.9%-5.1%) increase in PKEMLSI are expected. For every month after ACLR, a 0.2° (95% CI, 0.1°-0.4°) reduction in PKFDIFF and a 1.3% (95% CI, 0.6%-2.0%) increase in PKEMLSI are expected, controlling for PTLSI and RTDLSI.

CONCLUSION

Quadriceps RTDLSI was more strongly associated with symmetrical knee biomechanics during running compared with PTLSI or time throughout the first 2 years after ACLR.

Identification of Kinetic Abnormalities in Male Patients after Anterior Cruciate Ligament Deficiency Combined with Meniscal Injury: A Musculoskeletal Model Study of Lower Limbs during Jogging

There is little known about kinetic changes in anterior cruciate ligament deficiency (ACLD) combined with meniscal tears during jogging. Therefore, 29 male patients with injured ACLs and 15 healthy male volunteers were recruited for this study to investigate kinetic abnormalities in male patients after ACL deficiency combined with a meniscal injury during jogging. Based on experimental data measured by an optical tracking system, a subject-specific musculoskeletal model was employed to estimate the tibiofemoral joint kinetics during jogging. Between-limb and interpatient differences were compared by the analysis of variance. The results showed that decreased knee joint forces and moments of both legs in ACLD patients were detected during the stance phase compared to the control group. Meanwhile, compared with ACLD knees, significantly fewer contact forces and flexion moments in ACLD combined with lateral and medial meniscal injury groups were found at the mid-stance, and ACLD with medial meniscal injury group showed a lower axial moment in the loading response (p < 0.05). In conclusion, ACLD knees exhibit reduced tibiofemoral joint forces and moments during jogging when compared with control knees. A combination of meniscus injuries in the ACLD-affected side exhibited abnormal kinetic alterations at the loading response and mid-stance phase.

Knee Strength Assessment and Clinical Evaluation Could Predict Return to Running after Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Procedure

BACKGROUND AND OBJECTIVES

Muscle knee strength is a major parameter that allows return to running. Isokinetic strength parameters may predict return to running 4 months after ACLR using the bone-patellar-tendon-bone procedure.

MATERIALS AND METHODS

The isokinetic knee strength of 216 patients (24.5 ± 5 years) was measured 4 months after surgery, and progressive return to running was allowed. The effectiveness of return to running was reported at 6 months. Return to running prediction was established using multivariate logistic regression. Predictive parameters were presented with a ROC curve area to define the best cut-off, with sensibility (Se) and specificity (Sp).

RESULTS

A model was established, including the limb symmetry index (LSI), and 103 patients (47.6%) were able to run between the fourth and the sixth month after surgery. These patients presented significantly fewer knee complications, a better Lysholm score, a better Quadriceps and Hamstring LSI and better quadriceps strength reported for body weight on the operated limb. The best model was established including the Quadriceps and Hamstring LSI at 60°/s and the Lysholm score. The cut-off for Quadriceps LSI was 60% (ROC curve area: 0.847; Se: 77.5%; Sp: 77%), for Hamstring LSI 90% (ROC curve area: 0.716; Se: 65.7%; Sp: 60.2%) and for Lyshom score 97 points (ROC curve area: 0.691; Se: 65%; Sp: 66%).

CONCLUSION

Four months after ACLR using a bone-patellar-tendon-bone procedure, the Quadriceps and Hamstring LSI associated to the Lysholm score could help make the decision to allow return to running.

Knee Joint Biomechanics in Physiological Conditions and How Pathologies Can Affect It: A Systematic Review

The knee joint, as the main lower limb motor joint, is the most vulnerable and susceptible joint. The knee injuries considerably impact the normal living ability and mental health of patients. Understanding the biomechanics of a normal and diseased knee joint is in urgent need for designing knee assistive devices and optimizing a rehabilitation exercise program. In this paper, we systematically searched electronic databases (from 2000 to November 2019) including ScienceDirect, Web of Science, PubMed, Google Scholar, and IEEE/IET Electronic Library for potentially relevant articles. After duplicates were removed and inclusion criteria applied to the titles, abstracts, and full text, 138 articles remained for review. The selected articles were divided into two groups to be analyzed. Firstly, the real movement of a normal knee joint and the normal knee biomechanics of four kinds of daily motions in the sagittal and coronal planes, which include normal walking, running, stair climbing, and sit-to-stand, were discussed and analyzed. Secondly, an overview of the current knowledge on the movement biomechanical effects of common knee musculoskeletal disorders and knee neurological disorders were provided. Finally, a discussion of the existing problems in the current studies and some recommendation for future research were presented. In general, this review reveals that there is no clear assessment about the biomechanics of normal and diseased knee joints at the current state of the art. The biomechanics properties could be significantly affected by knee musculoskeletal or neurological disorders. Deeper understanding of the biomechanics of the normal and diseased knee joint will still be an urgent need in the future.