The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction

Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

INTRODUCTION

Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results.

REGISTRATION DETAILS

Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

'I want to ski and race, not just ski': a qualitative study on athletes' and stakeholders' perspectives on return-to-sport in high-performance Snowsports

This study explored stakeholders' perspectives on current practices, challenges and opportunities related to the return-to-sport (RTS) process in high-performance Snowsports. We conducted fourteen semi-structured interviews with athletes, coaches and health professionals from multiple countries using online video platforms. The data were transcribed verbatim and analysed based on constant comparative analysis employing the principles of Grounded Theory. Codes were grouped into categories and main concepts and a conceptual model were derived. According to the participants, RTS should be considered a continuous process to bring the athlete back to competition as fast and safely as possible, whereas speed is often prioritised over safety. Participants described the need for a structured and criteria-based process. Despite the multiple phases and the diversity of involved professionals, the process is individualised and unique, highlighting the value of having the athlete at the centre of the RTS process. It was considered essential to provide a safe environment and build trustworthy relationships. Additionally, access to resources, communication and cooperation among all experts was perceived as critical to successful RTS. Our participants described the value of continuity and an athlete-centred approach to the RTS process. The challenges, such as interprofessional communication, the lack of objective sport-specific criteria, and the diversity of resources and network structures, were perceived as practical issues that influenced the process, which should be tailored for each athlete accordingly to reach a successful RTS.

Are demographics, physical function and psychological response associated with return to sport at one year following ACL-reconstruction?

OBJECTIVE

To determine the relative contribution of each of the following aspects: demographics, physical function, and patient-reported outcome measures (PROMs), including both physical and psychological constructs, to return to sport (RTS) (any level) one-year post anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional cohort study.

METHODS

We included data for 143 participants (73 women, mean (SD) age 24 (5.8) years) ∼ one-year post-ACLR. Data comprised demographics, physical function (hop performance, hip and knee peak torque) and PROMs (Knee Osteoarthritis Outcome Score subscales, perceived stress, and ACL Return to Sport after Injury scale (ACL-RSI)). We then used a Z-normalized multivariable logistic regression model to establish the relative contribution of factors associated with RTS.

RESULTS

Sixty-four (45%) of the participants had returned to sport at one year post-ACLR. In the regression model, greater hip abduction peak torque (OR = 1.70, 95% CI; 1.01 to 2.84) and greater psychological readiness to RTS (OR = 2.32, 95% CI; 1.30 to 4.12) were the only variables associated with RTS (R2 = 0.352).

CONCLUSIONS

The significant contribution of hip abduction strength and psychological readiness to RTS was still relatively small, suggesting other potential factors explaining RTS which may not be captured by common RTS criteria.

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.

Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis

BACKGROUND

Psychological readiness is an important consideration for athletes and clinicians when making return to sport decisions following anterior cruciate ligament reconstruction (ACLR). To improve our understanding of the extent of deficits in psychological readiness, a systematic review is necessary.

OBJECTIVE

To investigate psychological readiness (measured via the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)) over time after ACL tear and understand if time between injury and surgery, age, and sex are associated with ACL-RSI scores.

METHODS

Seven databases were searched from the earliest date available to March 22, 2022. Articles reporting ACL-RSI scores after ACL tear were included. Risk of bias was assessed using the ROBINS-I, RoB-2, and RoBANS tools based on the study design. Evidence certainty was assessed for each analysis. Random-effects meta-analyses pooled ACL-RSI scores, stratified by time post-injury and based on treatment approach (i.e., early ACLR, delayed ACLR, and unclear approach).

RESULTS

A total of 83 studies were included in this review (78% high risk of bias). Evidence certainty was 'weak' or 'limited' for all analyses. Overall, ACL-RSI scores were higher at 3 to 6 months post-ACLR (mean = 61.5 [95% confidence interval (CI) 58.6, 64.4], I2 = 94%) compared to pre-ACLR (mean = 44.4 [95% CI 38.2, 50.7], I2 = 98%), remained relatively stable, until they reached the highest point 2 to 5 years after ACLR (mean = 70.7 [95% CI 63.0, 78.5], I2 = 98%). Meta-regression suggests shorter time from injury to surgery, male sex, and older age were associated with higher ACL-RSI scores only 3 to 6 months post-ACLR (heterogeneity explained R2 = 47.6%), and this reduced 1-2 years after ACLR (heterogeneity explained R2 = 27.0%).

CONCLUSION

Psychological readiness to return to sport appears to improve early after ACL injury, with little subsequent improvement until ≥ 2-years after ACLR. Longer time from injury to surgery, female sex and older age might be negatively related to ACL-RSI scores 12-24 months after ACLR. Due to the weak evidence quality rating and the considerable importance of psychological readiness for long-term outcomes after ACL injury, there is an urgent need for well-designed studies that maximize internal validity and identify additional prognostic factors for psychological readiness at times critical for return to sport decisions.

REGISTRATION

Open Science Framework (OSF), https://osf.io/2tezs/ .

Kinesiophobia in Injured Athletes: A Systematic Review

Athletes have a high risk of injury. Kinesiophobia is a condition in which an individual experiences a fear of physical movement and activity after an injury occurs. Our purpose was to systematically review the literature about Kinesiophobia in athletes. A systematic review was conducted in February 2023 using PubMed, CINAHL, SPORTDiscus, Web of Science, Cochrane Library, and Medline. Studies were included if they were peer-reviewed, in English, within the last 20 years and included athletes who had been injured and tracked Kinesiophobia. Articles were checked for quality via the modified Downs and Black checklist. Fourteen studies were included in the review and had an average "fair" quality score. Authors examined Kinesiophobia in injured athletes with mostly lower-extremity injuries. Kinesiophobia was associated with lower physical and mental outcomes. Kinesiophobia exists in athletes and can affect both physical and mental factors. The Tampa Scale of Kinesiophobia (TSK) was the most common tool used to examine Kinesiophobia. Common mental factors associated with Kinesiophobia include anxiety, low confidence, and fear avoidance.

Comparative Effectiveness of Supervised and Home-Based Rehabilitation after Anterior Cruciate Ligament Reconstruction in Competitive Athletes

Background: After the increasingly common anterior cruciate ligament reconstruction (ACLR) procedure in competitive athletes, rehabilitation is crucial for facilitating a timely return to sports (RTS) and preventing re-injury. This pilot study investigates the patient-reported outcomes of postoperative rehabilitation in competitive athletes, comparing supervised rehabilitation (SVR) and home-based rehabilitation (HBR). Methods: After ACLR, 60 (out of 74 screened) athletes were recruited and equally divided into HBR and SVR groups using non-probability convenience sampling, with each group comprising 15 males and 15 females. The rehabilitation outcomes in the respective groups were evaluated at 8 months using measures (Tegner Activity Scale [TAS], International Knee Documentation Committee subjective knee form [IKDC-SKF], ACL Return to Sport after Injury [ACL-RSI]) and objective parameters (isometric muscle strength, hamstring/quadricep asymmetry). RTS was evaluated at 9 months, with ACL re-injury rates recorded approximately 6 months post-RTS. Results: Both groups exhibited decreased TAS scores (HBR: 8 to 6, SVR: 8 to 7), with the SVR group demonstrating superior postoperative IKDC-SKF scores (81.82 vs. 68.43) and lower ACL-RSI scores (49.46 vs. 55.25). Isometric and isokinetic muscle strength, along with asymmetry values, was higher in the SVR group 8 months post-ACLR (p < 0.05). The SVR group showed a higher RTS rate to the same level (76.6% vs. 53.3%), while the re-injury rate was the same in both the rehabilitation groups (3.3%). Conclusions: Although both rehabilitation approaches yielded comparable outcomes, SVR may demonstrate some superior biomechanical improvements in athletes, resulting in a higher RTS rate. However, the psychological outcomes and re-injury rates did not significantly differ between the groups, emphasizing the need to address individual psychological needs during rehabilitation. Further investigation is recommended with a larger sample size to address the differences of gender among competitive athletes.

How Important are Psychological Measures to Determine Readiness to Return to Sports after Reconstruction of the Anterior Cruciate Ligament? An Online Survey Study

BACKGROUND

Recent studies have suggested that psychological factors are important components of a successful return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to survey physicians with respect to their criteria used to determine readiness to RTS after ACLR and to understand the significance of psychological factors on RTS.

METHODS

A survey was designed to understand the practices of clinicians managing rehabilitation after ACLR, consisting of 25 questions divided into 3 different sections, including one section about psychological scores and factors affecting RTS. The survey was delivered to three North American organizations for orthopedic sports medicine.

RESULTS

The total number of respondents was 113. Of the respondents, 95% considered psychological tests at least "somewhat important" (33% "important", 23% selected "very important"). Routine use of psychological tests in practice was only reported by 35% of respondents. The ACL-Return to Sport after Injury Scale was the most frequently used psychological test (23%). Fear of reinjury was considered the most common patient-cited psychological factor affecting RTS. Psychological factors ranked 8th out of 9 outcomes measures in determining readiness to RTS.

CONCLUSION

This study demonstrates a discrepancy between the importance of psychological tests and the frequency of use in practice. Additional education on this topic, web-based applications, and a multidisciplinary approach may increase the usage of psychological tests to determine RTS after ACLR.

Subjective Causes for Failure to Return to Sport After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

CONTEXT

While current literature has explored the outcomes of athletes who return to sport (RTS) after anterior cruciate ligament (ACL) injuries, less is known about the outcomes of those who are unsuccessful in returning to sport.

OBJECTIVE

To determine the rate of athletes who did not RTS after primary ACL reconstruction (ACLR) and to identify the specific subjective reasons for failure to RTS.

DATA SOURCES

A comprehensive search of the PubMed/MEDLINE, Scopus, and Web of Science databases was conducted through April 2021.

STUDY SELECTION

Eligible studies included those explicitly reporting the rate of failure for RTS after ACLR as well as providing details on reasons for athletes' inability to return; 31 studies met the inclusion criteria.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2 to 4.

DATA EXTRACTION

The reasons for failure to RTS referred to in our study are derived from those established previously in the studies included. Data were collected on the number of athletes, mean age, mean follow-up time, type of sport played, failure to RTS rate, and specific reasons for failure to return.

RESULTS

The weighted rate of failure to RTS after ACLR was 25.5% (95% CI, 19.88-31.66). The estimated proportion of psychosocial-related reasons cited for failure to RTS was significantly greater than knee-related reasons for failure RTS (55.4% vs 44.6%, P < 0.01). The most cited reason for failure to RTS was fear of reinjury (33.0%).

CONCLUSION

This study estimates the rate of failure to RTS after ACLR to be 25.5%, with the majority of athletes citing fear of reinjury as the major deterrent for returning to sports. We highlight how factors independent of surgical outcomes may impact an athlete's ability to return to play given that the predominant reason for no RTS after ACLR was unrelated to the knee.

Are inter-limb differences in change of direction velocity and angle associated with inter-limb differences in kinematics and kinetics following anterior cruciate ligament reconstruction?

BACKGROUND

Quantifying inter-limb differences in kinematics and kinetics during change of direction is proposed as a means of monitoring rehabilitation following anterior cruciate ligament reconstruction (ACLR). Velocity and centre of mass (CoM) deflection angle are fundamental task descriptors that influence kinematics and kinetics during change of direction. Inter-limb differences in approach velocity and CoM deflection angle have been identified following ACLR and may contribute to the presence of inter-limb differences in kinematics and kinetics during change of direction.

RESEARCH QUESTION

The aim of this study was to quantify the proportion of variance in kinematic and kinetic inter-limb differences attributable to inter-limb differences in approach velocity and centre of mass deflection angle during a change of direction task.

METHODS

A cohort of 192 patients (male, 23.8 ± 3.6 years, 6.3 ± 0.4 months post primary ACLR) completed a pre-planned 90° change of direction task on both their operated and non-operated limb. Inter-limb differences in approach velocity and CoM deflection angle were calculated alongside lower-extremity kinematic and kinetic variables. The relationship between inter-limb differences in task-level variables and inter-limb differences in kinematic and kinetic variables was examined using linear regression models. Kinematic and kinetic inter-limb differences were adjusted for inter-limb differences in approach velocity and CoM deflection angle. Adjusted and unadjusted inter-limb differences were submitted to one sample t-tests.

RESULTS

Inter-limb differences in approach velocity and centre of mass deflection angle explained 3 - 60% of the variance in kinematic and kinetic inter-limb differences. Statistical inferences remained consistent between adjusted and unadjusted conditions with the exception of hip flexion angle.

SIGNIFICANCE

Inter-limb differences in task-level features explain a large proportion of the variance in inter-limb differences in several kinematic and kinetic variables. Accounting for this variation reduced the magnitude of kinematic and kinetic inter-limb differences comparable to those previously observed in normative cohorts.

Effect of Postoperative Kinesio Taping on Knee Edema, Pain, and Range of Motion After Total Knee Arthroplasty and Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND

Kinesio taping (KT) has been shown to be clinically effective in a wide range of musculoskeletal disorders. Despite evidence supporting KT, there still needs to be more certainty regarding its clinical worthiness in managing postoperative conditions. This study aims to assess the effect of postoperative KT on knee edema, pain, and range of motion (ROM) when added to routine physiotherapy after knee surgery.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, Scopus, Web of Science, and CENTRAL databases were searched from their inception to July 2023. Randomized controlled trials (RCTs) comparing routine physiotherapy with and without KT were included. Random-effect models were used to calculate the standardized mean difference (SMD), confidence interval, and heterogeneity (I2).

RESULTS

Sixteen RCTs on 842 operated knees were included. KT reduced knee edema in first week (SMD, -0.59, p < 0.001), 14th postoperative day (POD) (SMD, -0.78, p < 0.001), and 28 to 42 days postop (SMD, -0.66, p < 0.001). The KT demonstrated significant pain improvement in second week (SMD, -0.87, p < 0.001) and the fourth week (SMD, -0.53, p < 0.001). The KT groups demonstrated ROM improvement within second week (SMD, 0.69, p = 0.010) and in the 28th POD (SMD, 0.89, p = 0.009). Subgroup analysis demonstrated minimal heterogeneity in anterior cruciate ligament reconstruction (ACLR) cases. However, it did not show significant superiority regarding ankle, calf, or thigh edema and Lysholm scale.

CONCLUSION

This study suggests that adding KT to routine postoperative physiotherapy reduces pain and knee edema after total knee arthroplasty or ACLR. Low to very low certainty of evidence for all outcomes and the limited number of studies emphasize the need for more high-quality primary studies to explore the optimal method of KT application and its effectiveness in specific knee surgeries.

LEVEL OF EVIDENCE

Level I. See Instructions for Authors for a complete description of levels of evidence.

The Influence of Strength and Sport Exposure on Psychological Readiness After ACL Reconstruction

BACKGROUND

Among young athletes returning to sport after anterior cruciate ligament reconstruction (ACLR), the extent to which psychological readiness is influenced by factors beyond the psychological domain is largely unknown.

HYPOTHESIS

Young athletes with recent sport exposure and higher quadriceps strength will demonstrate higher psychological readiness within 8 weeks of medical clearance to return to sport (RTS) after ACLR.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 38 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. All participants completed isometric knee extension strength testing, in addition to the ACL Return to Sport after Injury (ACL-RSI) questionnaire. Athletes who participated in sport between time of medical clearance to RTS and date of study enrollment were categorized as SPORT-YES. Those who had not yet participated in sports were categorized as SPORT-NO. Multiple linear regression analyses were used to determine differences in ACL-RSI scores based on quadriceps strength and sport exposure status, while adjusting for age and sex.

RESULTS

Of the 38 participants, 20 (52.6%) were categorized as SPORT-YES. The regression model estimating overall ACL-RSI score (P < 0.01, adjusted R2 = 0.389) included significant independent contributions from age, sex, and sport exposure variables (age: P = 0.01, β [95% CI] = -2.01 [-3.54, -0.48]; sex (male): P = 0.02, β [95% CI] = 12.50 [2.36, 22.64]; strength: P = 0.51, β [95% CI] = -2.47 [-10.07,5.13]; sport exposure: P < 0.01, β [95% CI] = 12.89 [3.58, 22.19]).

CONCLUSION

In partial accordance with our hypothesis, recent sport exposure was significantly associated with higher ACL-RSI scores among young athletes in the weeks after medical clearance to RTS after ACLR, while quadriceps strength was not.

CLINICAL RELEVANCE

Future prospective work is needed to determine the existence and direction of causal relationships between exposure to sport environment and psychological readiness among young athletes after ACLR.

How Mental Health Affects Injury Risk and Outcomes in Athletes

CONTEXT

The importance of mental health among athletes is becoming more recognized and valued. Athletes experience symptoms of depression, anxiety, and related mental health disorders at rates similar to those of the general population, but because athletes face unique cultural and environmental pressures, such disorders are exacerbated in the context of an injury. Furthermore, we review the less well-known evidence that mental health disorders in athletes are associated with an increased risk of injury. We discuss the increasing awareness of the deficiencies in mental health support for athletes, which has been especially highlighted during the COVID-19 pandemic as well as in prominent professional and Olympic athletes, and describe both internal and external barriers to appropriate care.

EVIDENCE ACQUISITION

We searched PubMed for pertinent peer-reviewed studies.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

There is a known psychological response to injury that can prolong recovery from musculoskeletal injury; conversely, mental health disorders in athletes are not only associated with an increased injury risk but also portend poorer outcomes subsequently, including prolonged recovery times, increased rates of injury recurrence, decreased rates of return to sport, and reduced performance upon return. Because of inherent barriers to appropriate care of athletes, including identification, stigma, and resource availability, there are currently various ongoing efforts nationally to create and implement initiatives regarding athlete mental health screening, support systems, and directed interventions to address the inextricably linked physical and mental health of athletes.

CONCLUSION

Athletic injury negatively impacts the mental health of athletes. Likewise, mental health can and does influence athletic performance and is also intimately tied to the risk of athletic injury, thus creating a complex cycle with inability to separate physical and mental health.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers

Background

While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this "rehabilitation gap."

Methods

The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients.

Results

Eighty-three percent of respondents experienced a "rehabilitation gap" with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the "rehabilitation gap." The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation.

Discussion

While the majority of our respondents acknowledged the existence of a "rehabilitation gap," as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.

Abnormal Lower Limb Biomechanics During a Bilateral Vertical Jump Despite the Symmetry in Single-Leg Vertical Hop Height in Athletes After ACL Reconstruction

Background

A limb symmetry index (LSI) of >90% for single-leg horizontal hop distance is recommended as a cutoff point for safe return to sports after anterior cruciate ligament reconstruction (ACLR). Despite achieving this threshold, abnormal lower limb biomechanics continue to persist in athletes after ACLR. Symmetry in single-leg vertical hop height appears to be more difficult to achieve and can be a better representation of knee function than single-leg horizontal hop distance.

Purpose

To explore whether an LSI of >90% for single-leg vertical hop height can represent normal lower limb biomechanics in athletes during a bilateral vertical jump after ACLR.

Study Design

Controlled laboratory study.

Methods

According to the LSI for single-leg vertical hop height, 46 athletes who had undergone ACLR with an autologous ipsilateral bone-patellar tendon-bone or hamstring tendon graft were divided into a low symmetry group (LSI <90%; n = 23) and a high symmetry group (LSI >90%; n = 23), and 24 noninjured athletes were selected as the control group. The kinematic and kinetic characteristics during a bilateral vertical jump were compared between the low symmetry, high symmetry, and control groups.

Results

During the propulsion phase of the bilateral vertical jump, the operated side in the high symmetry group showed a lower knee extension moment than the nonoperated side (P = .001). At peak vertical ground-reaction force, the operated side in the high symmetry group showed a lower knee internal rotation moment compared with the control group (P = .016). Compared with the nonoperated side, the operated side in the high symmetry group showed a higher hip extension moment (P = .002), lower knee extension moment (P < .001), lower ankle plantarflexion moment (P < .001), and lower vertical ground-reaction force (P = .023).

Conclusion

Despite achieving an LSI of >90% for single-leg vertical hop height, athletes after ACLR showed abnormal lower limb biomechanical characteristics during the bilateral vertical jump.

Clinical Relevance

Symmetrical single-leg vertical hop height may not signify ideal biomechanical or return-to-sports readiness in this population.

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate

PURPOSE

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports.

METHODS

This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively.

RESULTS

We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001).

CONCLUSIONS

At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Knee-Related Quality of Life Compared Between 20 and 35 Years After an Anterior Cruciate Ligament Injury Treated Surgically With Primary Repair or Reconstruction, or Nonsurgically

BACKGROUND

Quality of life (QoL) is affected up to 5 years after an anterior cruciate ligament (ACL) injury. Knee impairment and osteoarthritis (OA) development increase over time, and this may affect QoL at a long-term follow-up.

PURPOSE

To investigate changes in health- and knee-related QoL between 20 and 35 years after ACL injury and compare it between patients treated with or without ACL surgery, as well as to study how symptomatic OA (SOA) is associated with change in QoL.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between 1980 and 1983, 139 patients with acute ACL rupture were allocated to surgical or nonsurgical treatment of the ACL. Both groups completed a structured rehabilitation program. Of those patients, 59 were followed for 20 and 35 years after ACL rupture. After 10 crossovers, 33 patients were treated with primary repair or ACL reconstruction, and 26 were treated without ACL surgery. Combined radiographic OA and knee symptoms at 35 years was defined as SOA. QoL was assessed at 20 and 35 years after injury with the Knee injury and Osteoarthritis Outcome Score QoL (KOOS-QoL) subscale (range, 1-100), ACL-QoL questionnaire (total score and 5 subscales; range, 1-100), European QoL-5 Dimensions Questionnaire, and visual analog scale. Results were analyzed with paired and independent-sample t tests and chi-square tests.

RESULTS

Knee-related QoL was impaired at both 20 and 35 years after ACL injury, and differences were dependent on the measurement outcome. In the total cohort, KOOS-QoL did not change but both total ACL-QoL score (7.1 points; 95% CI, 2.2-11.9) and 4 of 5 subscales (5-10 points) decreased (P < .05). No differences were found between treatment groups. QoL decreased overall in patients with SOA, with a 21-point difference within-group change in KOOS-QoL (SOA or non-SOA) between 20 and 35 years of follow-up (P = .001; Cohen d = 1.0).

CONCLUSION

An ACL injury impairs knee-related QoL for up to 35 years, with no difference between treatment approaches (initial repair or later reconstruction compared with nonsurgical treatment). The deterioration decreases with longer follow-up. Clinicians should be aware of differences in QoL depending on the measurement outcome.

Differences in athletic identity, sport participation, and psychosocial factors following anterior cruciate ligament rehabilitation in youth athletes

Introduction

While youth sports benefits the developing athlete, athletes may also be subject to injury and subsequent return-to-sport protocols. The current return-to-sport criteria emphasize physical measures; however, psychological measures may also be valuable to inform providers of an athlete's readiness. One such measure is athletic identity defined as the degree to which an individual identifies with the athlete role. To better understand athletic identity in return-to-sport, this study aimed to identify relationships and trends between the Athletic Identity Measurement Scale (AIMS), demographic variables, sport participation measures, and the Athletic Coping Skills Inventory-28 (ACSI-28) in youth athletes during rehabilitation following anterior cruciate ligament reconstruction (ACLR).

Methods

A retrospective review was completed of patients who underwent ACLR at a sports medicine clinic between October 2019 and May 2021. Patients responded to a series of patient reported outcomes (PROs) regarding physical and psychological function at a pre-surgical baseline and after 1 year of rehabilitation. Patients were then divided into groups of high/low AIMS and an increased/decreased AIMS between 1 year and baseline for comparison. Independent samples t-tests and ANOVAs were performed as appropriate with a 95% confidence interval.

Results

In the final sample, 87 patients (15.3 ± 1.8 years) were included, with 51.7% being females. Total AIMS scores decreased from 50.3 to 47.5 over rehabilitation (p = 0.019). Furthermore, results indicated that nearly all AIMS scores decreased during rehabilitation, with none showing an increase; however, not all domains were significant. Conversely, all sport participation and coping ability PROs increased over time points except for ACSI-Confidence and Achievement Motivation. Generally, those in the groups with high AIMS and an increase in AIMS also had higher scores in physical function and coping ability PROs, with the groups separated by high/low AIMS exhibiting more frequent statistical significance.

Discussion

Given these results, it appears that athletes may lose identification with the athlete role after ACLR and struggle even 1 year for rehabilitation, but those who recover athletic identity the best may also be those able to cope most effectively with the stressors induced by injury.

Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) subcategories are affected by subjective running ability and medial single-leg hop distance in postreconstruction patients at 6 months

Purpose

This study aimed to investigate the intricate relationship between physical function factors and each subcategory score of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale among patients following ACL reconstruction.

Methods

Participants comprised 59 patients who had undergone primary ACL reconstruction using hamstring tendon. The ACL-RSI was completed 6 months after reconstruction and five physical functions were measured in patients on the same day. Simple linear regression was performed multiple times to investigate the relationship between ACL-RSI subcategory scores as a dependent variable and each independent variable (knee strength, leg anterior reach distance, single-leg hop [SLH] distances, side bridge endurance, and subjective running ability). Multiple regression analysis was performed using a stepwise method, with factors showing a risk rate <0.05 in simple linear regression analyses as independent variables and the ACL-RSI in each subcategory score as the dependent variable.

Results

Multiple regression analysis showed that subjective running ability affected all subcategories (p ≤ 0.001), and that the limb symmetry index of medial SLH distance affected both the Emotions (p = 0.047) and Confidence (p = 0.009) subcategories. Higher subjective running ability and greater limb symmetry in the medial SLH were thus positively associated with each dimension of psychological readiness.

Conclusions

This study highlights the differential impact of physical function factors on specific subcategories of the ACL-RSI scale, providing clinicians with insights for designing targeted rehabilitation strategies. This original paper suggests the importance of analysing factors related to subcategory scores in addition to total ACL-RSI score, and could contribute to the understanding of determinants for a successful return to sport following ACL reconstruction.

Level of Evidence

Level IV.

Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction

BACKGROUND

Approximately 1 in 4 athletes returning to sports will sustain a second anterior cruciate ligament (ACL) injury. Psychological factors related to kinesiophobia, confidence, and psychological readiness are associated with second ACL injury; however, the evidence is conflicting.

HYPOTHESIS

Athletes who sustain a second ACL injury (ie, graft rupture or contralateral ACL rupture) within 2 years of ACL reconstruction (ACLR) would have greater kinesiophobia, less confidence, and lower psychological readiness prior to return to sport (RTS) compared with athletes who do not sustain a second ACL injury.

STUDY DESIGN

Secondary analysis of a prospective randomized trial.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 39 female Level I/II athletes completed the following measures after postoperative rehabilitation and a 10-session RTS and second ACL injury prevention program: ACL Return to Sport after Injury (ACL-RSI) scale, the 11-item Tampa Scale of Kinesiophobia (TSK-11), and question 3 on the Knee injury and Osteoarthritis Outcome Score (KOOS) quality of life (QoL) subscale. Athletes were dichotomized based on whether they sustained a second ACL injury within 2 years of ACLR or not. Independent t tests determined group differences in TSK-11, KOOS-QoL, ACL-RSI, and the 3 individual components of the ACL-RSI (ie, emotions, confidence, risk appraisal).

RESULTS

Nine athletes sustained a second ACL injury (4 graft ruptures and 5 contralateral ACL ruptures). The group that sustained a second ACL injury had higher scores on the ACL-RSI (P = 0.03), higher on the risk appraisal questions of the ACL-RSI (P < 0.01), and met RTS criteria sooner than athletes who did not (P = 0.04). All second ACL injuries occurred in athletes who underwent primary ACLR with hamstring tendon autografts.

CONCLUSION

Athletes who sustained a second ACL within 2 years of ACLR had a more positive psychological outlook, higher scores on the specific questions related to the risk appraisal construct of the ACL-RSI, and met RTS criteria sooner than athletes who did not sustain a second ACL injury.

CLINICAL RELEVANCE

Counseling athletes about delaying RTS to reduce the risk of second ACL injury may be especially important in athletes who display high psychological readiness and meet RTS criteria sooner.

Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport

OBJECTIVES

To investigate current clinical practice of Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports physiotherapy or deep clinical experience and those without such experience.

DESIGN

Cross-sectional survey.

SETTING

Online survey platform.

PARTICIPANTS

Swiss physiotherapists.

MAIN OUTCOME MEASURES

The survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers.

RESULTS

A minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system.

CONCLUSION

This study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary.

Short-term fear of movement improves less after anterior cruciate ligament reconstruction with concomitant meniscus repair

BACKGROUND

Psychological response is important in return-to-sport decisions for athletes recovering from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare psychological response after ACLR with a concomitant meniscus repair compared to isolated ACLR.

METHODS

Thirty-five individuals completed the Tampa Scale of Kinesiophobia (TSK) and Anterior Cruciate Ligament Return-to-Sport after Injury (ACL-RSI) scale before ACLR and 2, 4, and 6 months after ACLR. Participants were dichotomized based on presence of concomitant meniscus repair (Yes/No). Separate group X time repeated measures analyses of variance were conducted for both scales.

RESULTS

Participants were 65.7% female, 19.1 ± 4.7 years old with BMI of 24.9 ± 4.4 kg/m2. Sixteen individuals had an isolated ACLR with 19 individuals having an ACLR with concomitant meniscus repair. For the TSK, there was a group × time interaction effect(p = 0.028), with improvement in TSK scores for the isolated ACLR group (ACLR:2 months = 24.8 ± 3.7; 4 months = 22.0 ± 5.7; 6 months: 19.9 ± 5.9; Meniscus Repair:2 months = 25.5 ± 4.7; 4 months = 24.1 ± 5.0; 6 months: 23.8 ± 4.7). Six months after ACLR, TSK scores were worse in the meniscus repair group(p = 0.036). For the ACL-RSI, there was no interaction(p = 0.07).

CONCLUSION

Concomitant meniscus repair with ACLR results in less post-operative improvement in kinesiophobia through 6 months after ACLR compared to isolated ACLR.

Non-Operative Rehabilitation Principles for Use in Individuals with Acetabular Dysplasia: A North American Based Delphi Study

Background

Acetabular dysplasia (AD) is defined as a structurally deficient acetabulum and is a well-recognized cause of hip pain in young adults. While treatment of severe AD with a periacetabular osteotomy has demonstrated good long-term outcomes, a trial of non-operative management is often recommended in this population. This may be especially true in patients with milder deformities. Currently, there is a paucity of research pertaining to non-operative management of individuals with AD.

Purpose

To present expert-driven non-operative rehabilitation guidelines for use in individuals with AD.

Study Design

Delphi study.

Methods

A panel of 15 physiotherapists from North America who were identified as experts in non-operative rehabilitation of individuals with AD by a high-volume hip preservation surgeon participated in this Delphi study. Panelists were presented with 16 questions regarding evaluation and treatment principles of individuals with AD. A three-step Delphi method was utilized to establish consensus on non-operative rehabilitation principles for individuals presenting with AD.

Results

Total (100%) participation was achieved for all three survey rounds. Consensus, defined a piori as > 75%, was reached for 16/16 questions regarding evaluation principles, activity modifications, appropriate therapeutic exercise progression, return to activity/sport criteria, and indications for physician referral.

Conclusion

This North American based Delphi study presents expert-based consensus on non-operative rehabilitation principles for use in individuals with AD. Establishing guidelines for non-operative management in this population will help reduce practice variation and is the first step in stratifying individuals who would benefit from non-operative management. Future research should focus on patient-reported outcomes and rate of subsequent surgical intervention to determine the success of the guidelines reported in this study.

Level of Evidence

Level V.

Self-reported knee function and activity level are reduced after primary or additional anterior cruciate ligament injury in female football players: a five-year follow-up study

BACKGROUND

Playing football involves a high risk of anterior cruciate ligament (ACL) injuries and these may affect knee function and activity level.

OBJECTIVES

To measure changes in self-reported knee function, activity level, and satisfaction with knee function and activity level in female football players with or without an ACL-reconstructed knee.

METHODS

Female football players, age 19.9 (SD 2.6) years, with either a primary ACL-reconstruction 1.6 (SD 0.7) years after ACL-reconstruction (n = 186) or no ACL injury (n = 113) were followed prospectively for five years. Self-reported data collected at baseline and follow-up included knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), activity level (Tegner Activity Scale), and satisfaction with knee function (Likert scale 1=happy; 7=unhappy) and activity level (1-10 scale). Information on any new ACL injury during the follow-up period was collected.

RESULTS

Players with ACL-reconstruction at baseline who either did (n = 56) or did not (n = 130) sustain an additional ACL injury, and players with no injury at baseline who remained injury free (n = 101) had a lower Tegner score at follow-up. Players with additional ACL injury had lower IKDC-SKF score (mean difference: -11.4, 95% CI: -16.0, -6.7), and satisfaction with activity level (mean difference: -1.5, 95% CI: -2.3, -0.7) at follow-up. Players with no additional ACL injury had higher satisfaction with knee function (mean difference: 0.6, 95% CI: 0.3, 0.9) at follow-up. Players with no ACL injury had lower satisfaction with activity level (mean difference: -0.7, 95% CI: -1.1, -0.3) at follow-up. Players with additional ACL injury had larger decreases in all variables measured compared to the two other groups.

CONCLUSION

Primary, and even more so additional, ACL injuries decreased self-reported knee function, activity level, and satisfaction with knee function and activity level in female football players.

Poorer patient-reported knee function and quality of life, but not activity level, after revision ACL reconstruction compared with primary ACL reconstruction: a matched-pair analysis with a minimum 5-year follow-up

BACKGROUND

An appropriate method for comparing knee function and activity level between patients with primary and revision anterior cruciate ligament reconstruction (ACLR) is to perform a matched-group analysis. The aim was to assess and compare knee function, knee-related quality of life and activity level between patients with revision ACLR and primary ACLR at a minimum of 5 years of follow-up.

METHODS

Patients aged ≤ 40 years old who underwent revision ACLR between 2010 and 2015 and a matched control group (primary ACLR) (1:1) with age ± 2 years, year of ACLR, sex, and pre-injury sport and Tegner Activity Scale (TAS) were retrospectively identified in our clinic database. The preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and surgical data were extracted and analyzed. Patients were mailed KOOS and EQ-5D questionnaires at a minimum of 5-years after revision ACLR. Study-specific questions about knee function, limitation in sport, satisfaction, and activity level according to the TAS (all scales of 1-10, 10 best) were also asked by telephone.

RESULTS

Seventy-eight patients with a revision ACLR (mean age ± SD, 29.9 ± 6.0 years) matched with seventy-eight patients with a primary ACLR (30.2 ± 5.8 years) were included. The follow-up for the revision ACLR group was 7.0 ± 1.5 years and for the primary ACLR group 7.7 ± 1.6 years. The revision ACLR group reported poorer KOOS scores in all subscales (p < 0.05) except the Symptoms subscale, poorer EQ-5D VAS (mean 79.2 ± 20.1 vs 86.0 ± 20.1, p = 0.012), and less satisfaction with current knee function (median 7 (6-8) vs 8 (7-9), p < 0.001). Patients with revision ACLR also experienced greater limitation in sports (median 7 (4-8) vs 8 (6-9), p < 0.001). There were no significant differences in the EQ-5D (mean 0.86 ± 0.17 vs 0.89 ± 0.11, p = 0.427), activity level (median 2 (2-5) vs 4 (2-7), p = 0.229), or satisfaction with activity level (median 8 (5-9) vs 8 (6-10), p = 0.281) between the groups.

CONCLUSIONS

At a minimum 5-year follow-up, the revision ACLR group reported poorer knee function and quality of life, less satisfaction with knee function and a greater limitation in sports but no differences in activity level and satisfaction with activity level compared with the primary ACLR group.

The Role of Strength-Related Factors on Psychological Readiness for Return to Sport Following Anterior Cruciate Ligament (ACL) Reconstruction

Psychological readiness following anterior cruciate ligament reconstruction (ACLR) correlates with different return to sport outcomes. However, the relationship between strength and power and psychological readiness remains unexplored. The aim of this study was to investigate the relationship between anterior cruciate ligament return to sport after injury (ACL-RSI) scores and various hamstrings and quadriceps strength and power variables. Twelve participants (20.7 ± 2.5 years old; 174.2 ± 7.5 cm; 70.2 ± 8.5 kg; 18.2 ± 8.3% of body fat) who had an ACLR nine months or more before the study completed the ACL-RSI questionnaire and isokinetic strength testing of the hamstrings and quadriceps (60°·s-1 and 180°·s-1). Based on ACL-RSI scores, they were divided into "cases" and "controls", deemed not psychologically ready and psychologically ready to return to previous sport performance (PILOS), respectively. The main findings are that quadriceps' and hamstrings' rate of torque development (RTD) and time since surgery were determinants of psychological readiness following ACLR. Furthermore, compared to controls, cases showed significantly lower quadriceps torque at angles close to full knee extension (40 deg and 30 deg from extension). They also showed lower RTD than controls, but no difference in peak torque. These results suggest that physiotherapists should facilitate athletes' return to sport (RTS) by focusing on the restoration of RTD and strength at angles close to full knee extension.

Criterion-Based Rehabilitation and Return to Play in Fast Bowlers Following Arthroscopic Bankart Repair: Recommendations Based on a Detailed Clinical Review

Background

Anterior shoulder instability due to labral tears in the dominant arm of cricket fast bowlers can be particularly disabling and results in significant match time loss. This often follows injuries sustained during fielding and training, although micro-instability following repetitive throwing progressing to overt anterior shoulder instability is also known. To ensure ball release speeds of over 140 km/h with different ball variations, these athletes require not only physical fitness and technical skill, but also a completely stable shoulder.

Methods

A literature search of "MEDLINE", "SPORT DISCUSS", and "GOOGLE SCHOLAR" was done to identify relevant articles published till the year 2023.

Results

A treatment approach that involves anatomic restoration of the shoulder via an arthroscopic Bankart capsulo-labral repair, followed by functional and biomechanical restoration via rehabilitation is the most predictable method to ensure a successful return to pre-injury fast-bowling status. A post-operative rehabilitation program that ensures a quick return to fast bowling without disrupting the surgical repair is crucial. Timely integration of exercises to recruit and strengthen the kinetic chain used for bowling and throwing plays a key role in this faster recovery. This current review provides a phase-wise, evidence-based rehabilitation guideline for return to competitive cricket after arthroscopic Bankart repair in a fast bowler. This review also highlights a structured return to bowling, throwing, and fielding program with a clinical decision-making process.

Conclusion

Exercise selection at an early stage that does not compromise the healing tissue, and timely integration of workouts to recruit and strengthen the kinetic chain used for bowling and throwing is the key strategy to allow faster recovery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00931-5.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study

BACKGROUND

Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes.

PURPOSE

To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS.

RESULTS

Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245).

CONCLUSION

A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients

BACKGROUND

The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them.

PURPOSE

To validate the ACL-RSI scale for use with pediatric and adolescent patients.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach's alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort.

RESULTS

A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach's alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions.

CONCLUSION

The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

It is time to target psychological readiness (or lack of readiness) in return to sports after Anterior Cruciate Ligament tears

Functional recovery has for long been the focus of rehabilitation after an Anterior Cruciate Ligament (ACL) injury. It is now increasingly recognized that more attention should be given to patients` mental recovery, their psychological readiness for returning to sport, after such an injury. Within this relatively new field of science, clinicians need clarity on when and how psychological factors should be monitored and how inexpedient psychological responses may be addressed during rehabilitation. In this Expert Opinion suggestions on how targeting psychological readiness may improve rehabilitation and return-to-sport evaluations are made based on current evidence-and issues in need of further clarification are addressed.

Clinically Relevant Subgroups Among Athletes Who Have Ruptured Their Anterior Cruciate Ligaments: A Delaware-Oslo Cohort Study

OBJECTIVE

To identify subgroups of individuals with anterior cruciate ligament (ACL) injuries based on patient characteristics, self-reported outcomes, and functional performance at baseline, and to associate subgroups with long-term outcomes after ACL rupture.

METHODS

A total of 293 participants (45.7% male, mean ± SD age 26.2 ± 9.4 years, days from injury 58 ± 35) were enrolled after effusion, pain, and range of motion impairments were resolved and quadriceps strength was at least 70% of the uninvolved limb. Mixture modeling was used to uncover latent subgroups without a prior group classification using probabilistic assignment. Variables include demographics, functional testing, and self-reported outcome measures. Radiographic evidence of osteoarthritis (OA; i.e., Kellgren/Lawrence grade of ≥1) in the involved knee at 5 years after injury was the primary outcome of interest. Chi-square tests assessed differences in the presence of radiographic OA in the involved knee between subgroups at 5 years after ACL rupture. Secondary outcomes of interest included radiographic OA in the uninvolved knee, return to preinjury sport by 2 years, operative status, and clinical OA (classified using Luyten et al criteria) at 5 years.

RESULTS

Four distinct subgroups exist after ACL rupture (younger good self-report, younger poor self-report, older poor self-report, older good self-report) with 30%, 31%, 47%, and 53%, respectively, having involved knee OA. The percentage of radiographic OA was not significantly different between the groups (P = 0.059).

CONCLUSION

The prevalence of OA in all subgroups is highly concerning. These results suggest there are unique subgroupings of individuals that may guide treatment after ACL rupture and reconstruction by providing support for developing a patient-centered approach.

Association of Psychological Readiness to Return to Sports With Subjective Level of Return at 12 Months After ACL Reconstruction

Background

Return-to-sports (RTS) rates after anterior cruciate ligament (ACL) reconstruction (ACLR) differ according to the level at which patients return. It is unclear whether the level of RTS is affected by psychological readiness to return.

Purpose

To examine the association between psychological readiness to RTS and subjective RTS level 12 months after ACLR.

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 47 patients who underwent unilateral primary ACLR surgery were enrolled. Assessments at 6 and 12 months postoperatively consisted of knee strength testing (isokinetic quadriceps and hamstring strength), the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness to RTS. Patients were assigned to 1 of 3 subgroups based on their subjective assessment of RTS level at 12 months postoperatively: RTS at or above preinjury level (RTS≥Pre; n = 19), RTS below preinjury level (RTS

Results

Significant differences were found among the RTS≥Pre, RTS

Conclusion

The ACL-RSI score was significantly different among the study groups, and the ACL-RSI score at 12 months postoperatively and younger age were associated with RTS at or above preinjury level.

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Key Words

• ACL-RSI
• knee strength
• patient-reported knee function
• performance

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MESH Headings Collapse

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Affiliation(s)

Makoto Suzuki Faculty of Health Sciences, Hokkaido University, Sapporo, Japan Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Tomoya Ishida Faculty of Health Sciences, Hokkaido University, Sapporo, Japan Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Hisashi Matsumoto Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Satoru Kaneko Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Chiharu Inoue Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Yoshimitsu Aoki Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Harukazu Tohyama Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
Mina Samukawa Faculty of Health Sciences, Hokkaido University, Sapporo, Japan

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The Association of Physical Competence With Psychological Response Among Young Athletes at Time of Return to Sport After ACL Reconstruction

BACKGROUND

The traditional index of return-to-sport (RTS) readiness after anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical mechanisms for successful RTS among young athletes.

HYPOTHESIS

Young athletes with higher actual physical competence (APC) and perceived physical competence (PPC) will demonstrate a more positive psychological response at the time of RTS after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 41 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. APC was measured with isokinetic knee extension strength, single-limb crossover hop for distance, and the Knee injury and Osteoarthritis Outcome Score. PPC was measured with the Athletic Competence subscale of the Self-Perception Profile. Criteria for APC and PPC were based on established age- and activity-relevant cutoff scores. Different constructs of psychological response were assessed with the adapted Sport Motivation Scale, Brief Resilience Scale, and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) total and subscale scores (Emotions, Confidence, and Risk Appraisal). Multiple linear regression analyses were used to determine differences in measures of psychological response based on achievement of APC and PPC, while adjusting for age and sex.

RESULTS

Of the 41 participants, 10 (24.4%) met all criteria for APC and 22 (53.7%) met the PPC criteria. The regression models estimating the ACL-RSI score (P < .001; adjusted R2 = 0.331), ACL-RSI Emotions score (P < .001; adjusted R2 = 0.427), and ACL-RSI Risk Appraisal score (P = .013; adjusted R2 = 0.212) were statistically significant. Although APC was not associated with any measure of psychological response, meeting PPC criteria, younger age, and male sex were found to be associated with a more positive psychological readiness to RTS, but not with motivation or resilience.

CONCLUSION

Meeting PPC criteria was associated with higher psychological readiness to RTS among young athletes after ACLR, while meeting APC criteria was not associated with any construct of psychological response.

Patients with unilateral ankle arthritis have decreased discrete and time-series limb symmetry compared to healthy controls

Patients with ankle arthritis (AA) have side-to-side limb differences at the ankle and in spatiotemporal measures; however, the degree of symmetry between limbs has not been compared to a healthy population. The purpose of this study was to determine differences in limb symmetry during walking for discrete and time-series measures when comparing patients with unilateral AA to healthy participants. Thirty-seven AA and 37 healthy participants were age, gender, and body mass index matched. Three-dimensional gait mechanics and ground reaction force (GRF) were captured during four to seven walking trails. GRF and hip and ankle mechanics were extracted bilaterally for each trial. The Normalized Symmetry Index and Statistical Parameter Mapping were used to assess discrete and time-series symmetry, respectively. Discrete symmetry was analyzed using linear mixed-effect models to determine significant differences between groups (α = 0.05). Compared to healthy participants, patients with AA had decreased weight acceptance (p = 0.017) and propulsive (p < 0.001) GRF, ankle plantarflexion (p = 0.021), ankle dorsiflexion (p = 0.010), and ankle plantarflexion moment (p < 0.001) symmetry. Significant regions of difference were found between limbs and groups throughout the stance phase for the vertical GRF force (p < 0.001), the ankle angle during push-off (p = 0.047), the plantarflexion moment (p < 0.001), and the hip extension angle (p = 0.034) and moment (p = 0.010). Patients with AA have decreased symmetry in the vertical GRF and at the ankle and hip during the weight acceptance and propulsive portions of the stance phase. Therefore, clinicians should try a non improving symmetry focusing on changing hip and ankle mechanics during the weight acceptance and propulsive phases of gait.

Kinesiophobia Is Negatively Associated With Psychological Readiness to Return to Sport in Patients Awaiting Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify the factors associated with anterior cruciate ligament return to sport after injury (ACL-RSI) scores in patients awaiting ACL reconstruction (ACLR).

METHODS

This was a retrospective cross-sectional observational study conducted at a single clinical center. We recruited patients scheduled for primary ACLR, aged 16-45 years, and with modified Tegner activity scale scores ≥5 before ACL injury. The main outcome was psychological readiness to return to sport (RTS), as measured using the ACL-RSI scale. Participants' personal and injury-related information were obtained, and their psychological status (Tampa Scale for Kinesiophobia [TSK] and athletic identity measurement scale) and knee functions (effusion, range of motion, joint stability, and knee flexion angle during a single-leg squat) were examined. All variables were assessed the day before the surgery.

RESULTS

A total of 105 patients (median [interquartile range]: age, 20.0 [9.0] years; body mass index, 22.8 [4.3] kg/m2; days from injury to surgery, 63.0 [65.0] days; 44% female) were enrolled. Univariate analysis indicated that only the TSK score was associated with the ACL-RSI scores (r = -0.305; P = .02). Multiple regression analysis of factors, including sex, preinjury Tegner activity scale score, and days from injury to surgery, further showed that only the TSK score was associated with the ACL-RSI scores (P = .002; 95% confidence interval -1.738 to -0.394).

CONCLUSIONS

In patients awaiting ACLR, kinesiophobia was moderately negatively associated with psychological readiness to RTS, while other factors were not.

LEVEL OF EVIDENCE

Level III, retrospective cross-sectional observational study.

Patients Who Return to Sport After Primary Anterior Cruciate Ligament Reconstruction Have Significantly Higher Psychological Readiness: A Systematic Review and Meta-analysis of 3744 Patients

BACKGROUND

Although objective outcomes assessing knee function are essential measurements for return to sport, psychological factors have become increasingly recognized as equally important parameters for determining an athlete's ability to return to sport after surgery.

PURPOSE

To systematically review the literature to determine whether patients who returned to sport after anterior cruciate ligament (ACL) reconstruction had improved psychological scores (as measured with validated questionnaires) compared with patients who did not return to sport.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 3.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was preregistered on PROSPERO. Four databases were searched for level 1 to 3 studies that compared at least 1 psychological outcome measured by a validated questionnaire for patients who did and did not return to sport after primary ACL reconstruction. The following data were recorded: study and patient characteristics; psychological metrics (ACL-Return to Sport Injury [ACL-RSI] scale, Knee Self-Efficacy Scale [K-SES], and Tampa Scale of Kinesiophobia [TSK/TSK-11]); International Knee Documentation Committee (IKDC) score; and clinical metrics. Study methodological quality was analyzed using the methodological index for non-randomized studies (MINORS), and the mean difference (MD) and 95% CI were calculated for each psychological outcome score using the inverse variance method.

RESULTS

We included and analyzed 16 articles (3744 patients; 38.9% female; mean age range, 17-28.7 years; mean MINORS score, 19.9 ± 1.4). Overall, 61.8% of athletes returned to sport (66.8% of male patients; 55.4% of female patients). Patients who returned scored significantly higher on the ACL-RSI scale (MD, 20.8; 95% CI, 15.9 to 25.7; P < .001), significantly higher on the K-SES (MD, 1.3; 95% CI, 0.2 to 2.3; P = .036), and significantly lower on the TSK/TSK-11 (MD, 10.1%; 95% CI, -12.1% to -8.2%; P = .004). Those returning to sport did not exceed the minimal clinically important difference for IKDC score versus those not returning to sport.

CONCLUSION

Patients who returned to sport after primary ACL reconstruction had significantly higher psychological readiness, higher self-efficacy, and lower kinesiophobia compared with those who did not return to sport, despite having clinically similar knee function scores. Evaluation of psychological readiness, in combination with other objective measurements, is a critical component of return-to-sport evaluation in athletes after primary ACL reconstruction.

REGISTRATION

CRD42021284735 (PROSPERO).

[Return to Sport (RTS) After Anterior Cruciate Ligament Reconstruction: Which Factors Influence the RTS Decision?]

BACKGROUND

It is unknown which valid criteria should be considered to justify the decision for return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR). The research question is whether gender, age, the outcome of the isokinetic maximal strength measurement and the single-leg hop test (quantitative/qualitative) influence the decision for RTS nine months after ACLR.

METHODS

This study is a retrospective data analysis. The research question was evaluated with a multiple logistic regression analysis (MLR). The dependent variable, RTS yes/no, is based on the decision of the orthopaedist in charge of treatment nine months (±30 days) after ACLR. The following possible influencing factors were investigated: gender, age, limb symmetry index (LSI) of maximal knee extension and knee flexion strength at 60°/sec., LSI of single-leg hop test and evaluation of knee valgus.

RESULTS

Data of 71 patients were included for MLR. The odds ratios (OR) for RTS increased with female gender (OR, 4.808; p=0.035), a higher LSI of maximal strength of knee extension (OR, 1.117; p=0.009) and a higher LSI of the single-leg hop test (OR, 1.125; p=0.020). Age, the LSI of maximal strength of knee flexion and knee valgus had no influence on the RTS decision.

CONCLUSION

Gender and the limb symmetry indexes of the maximal strength of knee extension and of the single-leg hop test are associated with RTS nine months after ACLR. These results should be considered to optimise rehabilitation after ACLR.

Brain Neuroplasticity Related to Lateral Ankle Ligamentous Injuries: A Systematic Review

BACKGROUND

Lateral ankle sprains are the most common ankle injuries in sports and have the highest recurrence rates. Almost half of the patients experiencing lateral ankle sprains develop chronic ankle instability. Patients with chronic ankle instability experience persistent ankle dysfunctions and detrimental long-term sequelae. Changes at the brain level are put forward to explain these undesirable consequences and high recurrence rates partially. However, an overview of possible brain adaptations related to lateral ankle sprains and chronic ankle instability is currently lacking.

OBJECTIVE

The primary purpose of this systematic review is to provide a comprehensive overview of the literature on structural and functional brain adaptations related to lateral ankle sprains and in patients with chronic ankle instability.

METHODS

PubMed, Web of Science, Scopus, Embase, EBSCO-SPORTDiscus and Cochrane Central Register of Controlled Trials were systematically searched until 14 December, 2022. Meta-analyses, systematic reviews and narrative reviews were excluded. Included studies investigated functional or structural brain adaptations in patients who experienced a lateral ankle sprain or with chronic ankle instability and who were at least 18 years of age. Lateral ankle sprains and chronic ankle instability were defined following the recommendation of the International Ankle Consortium. Three authors independently extracted the data. They extracted the authors' name, publication year, study design, inclusion criteria, participant characteristics, the sample size of the intervention and control groups, methods of neuroplasticity testing, as well as all means and standard deviations of primary and secondary neuroplasticity outcomes from each study. Data reported on copers were considered as part of the control group. The quality assessment tool for observational and cross-sectional studies was used for the risk of bias assessment. This study is registered on PROSPERO, number CRD42021281956.

RESULTS

Twenty articles were included, of which only one investigated individuals who experienced a lateral ankle sprain. In all studies combined, 356 patients with chronic ankle instability, 10 who experienced a lateral ankle sprain and 46 copers were included. White matter microstructure changes in the cerebellum have been related to lateral ankle sprains. Fifteen studies reported functional brain adaptations in patients with chronic ankle instability, and five articles found structural brain outcomes. Alterations in the sensorimotor network (precentral gyrus and supplementary motor area, postcentral gyrus and middle frontal gyrus) and dorsal anterior cingulate cortex were mainly found in patients with chronic ankle instability.

DISCUSSION

The included studies demonstrated structural and functional brain adaptations related to lateral ankle sprains and chronic ankle instability compared to healthy individuals or copers. These adaptations correlate with clinical outcomes (e.g. patients' self-reported function and different clinical assessments) and might contribute to the persisting dysfunctions, increased re-injury risk and long-term sequelae seen in these patients. Thus, rehabilitation programmes should integrate sensorimotor and motor control strategies to cope with neuroplasticity related to ligamentous ankle injuries.

Preoperative predictors for return to physical activity following anterior cruciate ligament reconstruction (ACLR): a systematic review

BACKGROUND

Rates of return to physical activity after anterior cruciate ligament reconstruction surgery are sub-optimal. Optimising presurgical treatment may improve return rates. The purpose of this systematic review was to identify modifiable preoperative predictors for return to physical activity after anterior cruciate ligament reconstruction.

METHODS

Seven electronic databases (CINAHL, MEDLINE and SPORTDiscus via EBSCOhost, AMED, PsycINFO and EMBASE via OVID and Web of Science) were searched from inception to 31 March 2023. The population of focus was adults aged 18-65 who had undergone primary anterior cruciate ligament reconstruction. Studies needed to identify at least one potential modifiable preoperative predictor variable and the relationship between the predictor(s) and return to physical activity. All time-points of assessment and study designs were included. Data extraction was completed by one reviewer and verified by a second reviewer. Two reviewers completed the risk of bias assessment using the Quality in Prognostic Studies tool and Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The search identified 2281 studies, eight met the inclusion criteria. Five studies scored 'high', and three studies scored 'moderate' risk-of-bias. All preoperative predictors were of very low-quality evidence. Five different outcome measures were used to assess return to physical activity including Tegner, Marx, Physical Activity Scale, return to play at the elite level and return to preinjury level (undefined). This was measured between 1- and 10-years post-surgery. Nine preoperative physical, six psychosocial and five demographic/clinical factors were assessed and four were found to be predictive. These included quadriceps strength, psychological profile, patient estimated ability to return and graft type (patella tendon, BPTB).

CONCLUSION

Very-low level evidence suggests that increasing quadriceps strength, managing patient expectations of their treatment outcomes, improving motivation to resume preinjury activity levels and considering the use of a BPTB graft will support return to physical activity after ACLR.

TRIAL REGISTRATION

This study was prospectively registered in PROSPERO: CRD 42020222567.

Comparison of Psychological Readiness to Return to Sport After Primary Versus Revision Anterior Cruciate Ligament Reconstruction

Background

Rates of return to preinjury level of play after anterior cruciate ligament (ACL) reconstruction (ACLR) remain unsatisfactory, particularly for patients who undergo revision surgery. Psychological readiness is associated with successful return to sport (RTS) and self-perceived preinjury sport performance.

Purpose

To compare psychological readiness at RTS between patients who underwent revision ACL autograft reconstruction and matched controls who underwent primary ACL autograft reconstruction.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were gathered using a single orthopaedic surgeon database of patients who underwent ACLR between 2015 and 2018. Patients who underwent revision ACLR and met the study criteria (N = 92) were matched by age, sex, graft type, and rehabilitation protocol to a control group of patients who underwent primary ACLR (n = 92). Functional assessment at release to play was examined using passive knee range of motion, single-leg squat, and single-leg hop testing. Self-reported outcomes included the International Knee Documentation Committee subjective function survey and the ACL-Return to Sport after Injury (ACL-RSI) psychological readiness scale. Time to release to play was recorded as the number of months needed to reach a ≥90% limb symmetry index from the date of the index ACLR. Data were assessed for normality using the Shapiro-Wilk test, and univariate general linear models were utilized with an alpha level of .05.

Results

The overall mean patient age was 29.9 ± 10 years, and 40% of patients were women. No significant differences between groups were noted in any of the baseline patient characteristics or surgical findings. At RTS, the mean ACL-RSI score was significantly lower in the revision surgery group (77.4 ± 19.4 vs 85.3 ± 17.4; P = .011). In addition, the revision surgery group returned to play significantly later than the primary surgery group (9.4 ± 2 vs 8.1 ± 1.3 months, respectively; P < .001).

Conclusion

When compared with primary ACL autograft reconstruction, revision reconstruction patients exhibited lower psychological readiness scores and a longer time to meet the objective criteria for RTS.

Registration

NCT03704376 (ClinicalTrials.gov identifier).

The experience and influence of fear after anterior cruciate ligament reconstruction: an interview study with young athletes

BACKGROUND

Despite good physical function, many athletes do not return to sports after an anterior cruciate ligament reconstruction (ACLR). One important reason for this is fear of new injury. The aim of this study was to investigate young athletes' experiences of knee-related fear after an ACLR and how they perceive this fear to affect them in their sporting and everyday life.

METHODS

A qualitative interview study was conducted, using semi-structured interviews. Athletes who were active in contact or pivoting sport before an ACL injury, with the goal of returning to the same sport and who scored highly on fear of new injury at six months post-ACLR, were asked to participate. Ten athletes (six women and four men, aged 17-25 years), were interviewed by an independent researcher, 7-9 months after ACLR. Content analysis employing an abductive approach was used.

RESULTS

The analysis resulted in three categories with associated subcategories: 1. The expressions of fear; (i) reason for fear, (ii) changes in fear over time, and (iii) injury situation. 2. Reactions, consequences, and adaptations; (i) reactions, (ii) behavioural adaptation and influence on rehabilitation and daily life, (iii) present consequences, and (iv) consequences for the future. 3. Fear and adaptations related to returning to sports; (i) fear related to returning to sports and, (ii) adaptations in sports and life due to fear. Fear was described in broad and complex ways, with fear of a new injury being expressed as one of several aspects. Various reasons (e.g., seeing others getting injured in the past, previous experience of injury, failed rehabilitation, perceived knee instability) were given to explain the fear, and athletes reacted both physically and mentally to fear. Both positive and negative adaptations to fear were described, in both daily life and sports.

CONCLUSION

The results contribute to an increased understanding of fear as an essential psychological factor to consider during rehabilitation and leaves the way open for research to investigate how physiotherapists can work to manage fear better among ACLR patients.

Higher Grit Scores Are Associated With Earlier Increases in Knee Flexion Following Anterior Cruciate Ligament Reconstruction With Meniscus Repair in Pediatric Patients

BACKGROUND

The Grit Scale is used to measure grit, defined by Duckworth and colleagues as the disposition to show perseverance and passion for long-term goals. It has been shown that psychological factors like motivation, coachability, and coping with adversity are correlated with faster readiness for return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction (ACLR). This study investigates the association between pediatric patients' baseline grit scores and; preoperative Patient-reported Outcomes Measurement Information System (PROMIS) Pain scores and the recovery of range of motion (ROM) after ACLR. The investigators hypothesized that higher preoperative grit scores would predict lower preoperative pain scores and earlier return of knee ROM in patients undergoing ACLR.

METHODS

This is a retrospective cohort study. Pediatric patients who underwent primary ACLR were assigned the pediatric Grit Scale. Patients were subdivided by meniscal procedures due to differences in postoperative protocols. ACLR alone or with meniscectomy (ACLR ± meniscectomy) were grouped together and ACLR with meniscal repair (ACLR + meniscus repair) represented the other cohort. Patients above the 50th grit percentile were considered "high grit". Patients below the 50th percentile were considered "low grit". Baseline PROMIS pain intensity and interference were collected. ROM was compared by grit cohort using the Mann-Whitney U test with a significance threshold of P ≤ 0.05.

RESULTS

A total of 58 patients undergoing ACLR were analyzed: 20 ACLR ± meniscectomy and 38 ACLR + meniscus repair. The mean age was 15.0 ± 2.1 years with 41.4% of participants identifying as females. No significant difference was noted between baseline PROMIS pain intensity and interference and grit score ( P = 0.82, P = 0.91, respectively). Three months postoperatively, for those in the ACLR + meniscus repair cohort, low grit ROM was 130 degrees (interquartile range = 10 degrees), whereas high grit ROM was 135 degrees (interquartile range = 8 degrees) ( P = 0.006).

CONCLUSIONS

This study found no differences in pain scores at presentation between grit cohorts but found that patients with grit scores below the 50th percentile undergoing ACLR + meniscus repair have 5 degrees less total ROM at 3 months compared with those with high grit scores. Quicker ROM recovery in patients with high grit may be a leading indicator of these patients' likelihood to achieve other postoperative milestones and meet criteria for RTS more quickly; the relationship between grit and readiness for RTS should be further investigated.

LEVEL OF EVIDENCE

Level IV; retrospective cohort study.

The Relationship of Knee-related Quality of Life With Function, Psychological Factors, Strength, Performance, and Postural Stability After ACL Reconstruction: A Cross-Sectional Study

BACKGROUND

Patients after anterior cruciate ligament reconstruction (ACLR) have decreased health-related quality of life (QoL) compared with healthy control participants. Few studies have verified the predictors of QoL using Quality of Life Outcome Measure Questionnaire for Chronic Anterior Cruciate Ligament Deficiency (ACL-QoL), and no study has verified the relationship of psychological factors and knee function with ACL-QoL in patients after ACLR.

HYPOTHESIS

Knee functional status, muscle strength, performance in hop tests, postural stability, and psychological factors would be the predictors of QoL after ACLR.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 131 participants who had undergone ACLR at least 6 months previously were evaluated. QoL was assessed using ACL-QoL; knee functional status, using International Knee Documentation Committee Subjective Knee (IKDC) and global rating scale (GRS); psychological readiness, using Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI); kinesiophobia, using Tampa Scale for Kinesiophobia (TSK-17); knee strength, using isokinetic dynamometer; performance, using single-leg hop tests; and postural stability, using Biodex Balance System. Pearson's linear correlation and stepwise hierarchical multiple linear regression analyses were performed to verify the predictors of QoL.

RESULTS

ACL-QoL showed a moderate correlation with IKDC (r = 0.69), GRS (r = 0.55), ACL-RSI (r = 0.50), and TSK-17 (r = -0.49). ACL-QoL presented none to low correlations with the variables of muscle strength, postural stability, and performance in hop tests. The variables related to the knee functional status and psychological factors (IKDC, GRS, ACL-RSI, and TSK-17) were found to be the predictors of QoL (R2 = 0.56; P = 0.01).

CONCLUSION

Knee functional status, psychological readiness, and kinesiophobia were the predictors of knee-related QoL in patients after ACLR.

CLINICAL RELEVANCE

These results can assist clinicians in the therapeutic monitoring of the factors that may interfere with QoL in patients after ACLR.

Relationship Between Quadriceps Strength and Knee Joint Power During Jumping After ACLR

Background

Knee joint power is significantly impaired during the propulsive phase of jumping after anterior cruciate ligament reconstruction (ACLR); however, it is currently unknown how quadriceps strength influences knee joint power.

Purpose

To (1) evaluate the relationship between quadriceps strength, joint power, and the percentage contribution of the hip, knee, and ankle joints to total limb power during the propulsive phase of jumping and (2) establish a quadriceps strength cutoff value for maximizing the likelihood of having knee joint power characteristics similar to healthy participants.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 75 participants were included in this study-40 patients who underwent ACLR 6 months before (18 females; mean age, 19.3 ± 5.7 years) and 35 healthy controls (HC) (20 females; mean age, 21.5 ± 4.5 years). Participants performed a drop vertical jump and underwent isometric quadriceps strength testing. The peak joint power was calculated as the product of the internal joint moment and joint angular velocity. Pearson product-moment correlations were used to assess the relationship between quadriceps strength and knee joint power. Paired samples t tests were used to quantify differences between limbs. Receiver operating characteristic (ROC) curve analysis was used to determine a quadriceps strength cutoff.

Results

The involved limbs of the ACLR cohort (INV) had significantly lower peak knee joint power and percentage contribution from the knee joint during jumping compared with the uninvolved limbs (NON) and limbs of the controls (INV, 2.5 ± 1.2 W/kg; NON, 4.4 ± 1.5 W/kg; HC, 4.3 ± 1.7 W/kg [P < .0001]). Quadriceps strength was associated with knee joint power in involved limbs and limbs of controls (INV, r = 0.50; HC, r = 0.60). A quadriceps strength cutoff value of 2.07 N·m/kg had an area under the ROC curve of 0.842, indicating good predictive accuracy.

Conclusion

Athletes at 6 months after ACLR demonstrated knee-avoidant jumping mechanics and had significant reductions in knee joint power on the involved limb. A quadriceps strength cutoff value of 2.07 N·m/kg can help predict which athletes will display knee joint power characteristics similar to those of healthy controls.

Patient-Reported Measures Associated with the Return to Pre-Injury Levels of Sport 2 Years after Anterior Cruciate Ligament Reconstruction

The International Knee Documentation Committee Subjective Knee Form (IKDC2000) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) are knee-specific measures. However, their association with a return to sports after anterior cruciate ligament reconstruction (ACLR) is unknown. This study aimed to investigate the association between the IKDC2000 and the KOOS subscales and the return to the same pre-injury level of sport two years after ACLR. Forty athletes that were two years post-ACLR participated in this study. Athletes provided demographic information, filled out the IKDC2000 and KOOS subscales, and indicated whether they returned to any sport and whether they returned to the same pre-injury level (same duration, intensity, and frequency). In this study, 29 (72.5%) athletes returned to play any sport and eight (20%) returned to the same pre-injury level. The IKDC2000 (r: 0.306, p = 0.041) and KOOS quality of life (KOOS-QOL) (r: 0.294, p = 0.046) significantly correlated with the return to any sport, but it was age (r: -0.364, p = 0.021), BMI (r: -0.342, p = 0.031), IKDC2000 (r: 0.447, p = 0.002), KOOS-pain (r: 0.317, p = 0.046), KOOS sport and recreation function (KOOS-sport/rec)(r: 0.371, p = 0.018), and KOOS QOL (r: 0.580, p > 0.001) that significantly correlated with a return to the same pre-injury level. High KOOS-QOL and IKDC2000 scores were associated with returning to any sport, and high KOOS-pain, KOOS-sport/rec, KOOS-QOL, and IKDC2000 scores were all associated with returning to the same pre-injury level of sport.

Psychological readiness is related to return to sport in judo injuries: a cross-sectional study

BACKGROUND

The aim of this study is to investigate the influence of a judoka's psychological readiness in relation to his ability to return to sport. At the present time, the relationship between physical and psychological readiness to return to sport has not been adequately elucidated.

METHODS

This is a cross-sectional study. An online survey was distributed via social networks and the German Judo Association collecting data from competitive and recreational judo athletes. The survey collected data on participants' characteristics, history of injury, and psychological readiness to return to sport after injury as determined by either the Anterior Cruciate Ligament-Return to Sport after Injury Scale, the Shoulder Instability-Return to Sport after Injury Scale, or a modified version of the Return to Sport after Injury Scale depending on the respective type of injury.

RESULTS

The study included 383 judo athletes (272 competitive judo athletes and 112 recreational judo athletes). Regardless of injury location, athletes who achieved return to sports (M = 70.67; SD = 16.47) had higher RSI scores than athletes that did not return to sports (M = 53.88; SD = 19.12; p < 0.0001). Male athletes (M = 65.60; SD = 19.34) did show significantly higher RSI scores than female athletes (M = 60.45; SD = 19.46). The RSI score differed for different time loss categories, F(7, 375) = 11.309, p < 0.001, η² = .174 with decreasing RSI scores for longer time loss and lowest RSI scores in athletes, who never returned to sports. RSI scores of athletes with knee injuries differed from athletes with other injury locations (10.23, 95% CI [4.08, 16.38]). After adjusting for time loss due to injury, competitive athletes had higher RSI scores than competitive athletes (F (1, 382) = 7.250, p < 0.001, partial η² = .02). Conservatively treated athletes (M = 66.58; SD = 18.54) had higher RSI scores than surgically treated athletes (M = 59.05; SD = 20.01; p < 0.05).

CONCLUSION

Based on the data of this study, type of injury, sport level, treatment method, and gender appear to influence psychological readiness on judoka and their ability to return to sport. The multiple factors that influence a judoka and their ability to return to sport argue for individualized treatment of judoka and their psychological state after injury in the return to sport process.

Understanding Fear after an Anterior Cruciate Ligament Injury: A Qualitative Thematic Analysis Using the Common-Sense Model

Fear is a significant factor affecting successful return to sport following an anterior cruciate ligament (ACL) injury. However, there is a lack of understanding of the emotional drivers of fear and how fear beliefs are formed. This study qualitatively explored the contextual and emotional underpinnings of fear and how these beliefs were formed, with reference to the Common-Sense Model of Self-Regulation. Face-to-face online interviews were conducted with ACL-injured participants (n = 18, 72% female) with a mean age of 28 years (range 18-50 years). Participants were either 1 year post ACL reconstruction surgery (n = 16) or at least 1 year post injury without surgery (n = 2) and scored above average on a modified Tampa Scale of Kinesiophobia. Four participants were playing state-level sport or higher. Five themes emerged describing factors contributing to fear: 'External messages', 'Difficulty of the ACL rehabilitation journey', 'Threat to identity and independence', 'Socioeconomic factors', and 'Ongoing psychological barriers'. A sixth theme, 'Positive coping strategies', provided insight into influences that could reduce fear and resolve negative behaviors. This study identified a broad range of contextual biopsychosocial factors which contribute to fear, supporting the notion that ACL injuries should not be treated through a purely physical lens. Furthermore, aligning the themes to the common-sense model provided a conceptual framework conveying the inter-related, emergent nature of the identified themes. The framework provides clinicians with a means to understanding fear after an ACL injury. This could guide assessment and patient education.

The Comparison of Psychological Barriers Between Individuals with a History of Anterior Knee Pain, Anterior Cruciate Ligament Reconstruction, and Healthy Individuals

Background

Psychological barriers due to anterior knee pain (AKP) and anterior cruciate ligament reconstruction (ACLR) may have a direct impact on an individual's return to physical activity. A comprehensive understanding of these psychological barriers in individuals with AKP and ACLR may help clinicians to develop and implement better treatment strategies to address deficits that may exist in these individuals.

Hypothesis/Purpose

The primary purpose of this study was to evaluate fear-avoidance, kinesiophobia, and pain catastrophizing in individuals with AKP and ACLR compared with healthy individuals. The secondary purpose was to directly compare psychological characteristics between the AKP and ACLR groups. It was hypothesized that 1) individuals with AKP and ACLR would self-report worse psychosocial function than healthy individuals and 2) the extent of the psychosocial impairments between the two knee pathologies would be similar.

Study Design

Cross-sectional study.

Methods

Eighty-three participants (28 AKP, 26 ACLR, and 29 healthy individuals) were analyzed in this study. Fear avoidance belief questionnaire (FABQ) with the physical activity (FABQ-PA) and sport (FABQ-S) subscales, Tampa scale of Kinesiophobia (TSK-11) and pain catastrophizing scale (PCS) assessed psychological characteristics. Kruskal-Wallis tests were used to compare the FABQ-PA, FABQ-S, TSK-11, and PCS scores across the three groups. Mann-Whitney U tests were performed to determine where group differences occurred. Effect sizes (ES) were calculated with the Mann-Whitney U z-score divided by the square root of the sample size.

Results

Individuals with AKP or ACLR had significantly worse psychological barriers compared to the healthy individuals for all questionnaires (FABQ-PA, FABQ-S, TSK-11, and PCS) (p<0.001, ES>0.86). There were no differences between the AKP and ACLR groups (p≥0.67), with a medium ES (-0.33) in the FABQ-S between AKP and ACLR groups.

Conclusion

Greater psychological scores indicate impaired psychological readiness to perform physical activity. Clinicians should be aware of fear-related beliefs following knee-related injuries and are encouraged to measure psychological factors during the rehabilitation process.

Level of Evidence

2.

Adding A Structured Educational Session to the Rehabilitation Program of Soccer Players Following Anterior Cruciate Ligament Reconstruction: A Feasibility Study

Background

While a lack of psychological preparedness and fear of movement may be linked with the anterior cruciate ligament (ACL) re-injury, these variables are rarely addressed throughout the therapy stages via educational sessions. Unfortunately, in terms of reducing fear, increasing function, and returning to play, no research has been done yet on the efficacy of adding organized educational sessions to the rehabilitation programs of soccer players post-ACL reconstruction (ACLR). Therefore, the study's aim was to assess the feasibility and acceptability of adding organized educational sessions to the rehabilitation programs post-ACLR.

Methods

A feasibility randomized controlled trial (RCT) was conducted in a specialized sports rehabilitation center. Participants post ACL reconstruction were randomized to either usual care with a structured educational session (intervention group) or usual care alone (control group). This feasibility study investigated three aspects: recruitment, intervention acceptability and randomization, and retention. The outcome measures included Tampa Scale of Kinesiophobia, ACL-Return to Sport after Injury, and International Knee Documentation Committee for knee function. Measurements were done at baseline and one week after the intervention.

Results

All of the 36 players who were undergoing rehabilitation post-ACLR at the center at the time of the study were invited to participate in the study. Thirty-five players (97.2%) agreed to participate in the study. The participants responded to some questions about the acceptability of the intervention and randomization and most of them thought they were appropriate. 30 (85.7%) participants completed the follow-up questionnaires one week after the randomization.

Conclusion

This feasibility research found that adding a structured educational session to the rehabilitation program for soccer players after ACLR is feasible and acceptable. Full-scale RCTs with longer follow-ups and multiple locations are recommended.

Composite Score of Readiness (CSR) as a Data Reduction Technique for Monitoring the RTS Process in Footballers following ACL Reconstruction

In recent years, many studies on the safe return to sport (RTS) have been published, but there are still no clear and validated guidelines. After ACL reconstruction between limbs, asymmetry of muscle strength affects knee mechanics during walking and running, and asymmetrical joint kinematics and kinetics are considered as a strong risk factor of musculoskeletal injury. Therefore, proper diagnosis of any motor deficits remaining after ACL reconstruction seems particularly important. The aim of this study was to analyze how many tests should be included in the RTS test battery and which of them are most indicative for functional deficits related to anterior cruciate ligament (ACL) reconstruction. Sixty-five male football players (age 18–25 years) were divided into three groups: ACL group—after ACL rupture and reconstruction, mild injury group—post mild lower limb injuries, and the control group—without injuries. They performed five tests: Functional Movement Screen, Tuck Jump Assessment, Y-balance Test, Hop Test for Distance, and Isokinetic Test. The Composite Score of Readiness (CSR) index was calculated and expressed as the sum of z-scores. The multiple regression model for all tests was calculated, and then redundant variables were excluded. We observed that all tests significantly influenced the final CSR index. The Y-balance Test, Tuck Jump Assessment, and Isokinetic Test for knee flexion influenced the final CSR index the most, which means that these tests are greatly indicative of functional deficits related to ACL reconstruction. The strength of the extensor (quadriceps) muscle and the quadriceps/hamstring ratio appeared to be non-sensitive for testing functional deficits related to ACL reconstruction. If the test battery includes 4–5 tests, it better differentiates the athletes following ACL reconstruction from those after mild injuries, even if they all were cleared to play.