Factors Associated With a Return to Preinjury Level of Sport Performance After Anterior Cruciate Ligament Reconstruction Surgery

Relationship Between Single-Leg Vertical Jump and Drop Jump Performance, and Return to Sports After Primary Anterior Cruciate Ligament Reconstruction Using Hamstring Graft

Background

After anterior cruciate ligament reconstruction (ACLR), asymmetry is likely to persist in single-leg (SL) vertical jump and drop jump performance than in SL hop distance. However, its relationship with the return to sport (RTS) remains unclear.

Hypothesis/Purpose

This study aimed to determine the association between vertical jump performance after primary ACLR using hamstring tendon autograft and RTS at a pre-injury competitive level.

Study design

Cross-sectional study.

Methods

Patients who underwent primary ACLR using hamstring tendon autograft were recruited for this study. Participants who returned to pre-injury competition after ACLR were recruited at least eight months postoperatively. Knee condition was assessed, including joint laxity, range of motion, muscle strength, and knee pain intensity during sports activities. Performance variables were also assessed, including SL hop distance, jump height in SL vertical jump, and reactive strength index (RSI; jump height/contact time) in SL drop jump. Participants were asked to subjectively report whether they had returned to the same level of competition as pre-injury and their perceived sport performance intensity. Those who answered "Yes" to the dichotomous question and had a postoperative subjective athletic performance of > 80% were categorized into the Yes-RTS group. The primary outcome was the ability to achieve RTS at the preinjury level.

Results

Sixty-five patients (female, 35; male, 30) at 13.0 (13.0) [median (interquartile)] months after ACLR participated in this study. Thirty-nine (60%) were assigned to the Yes-RTS group. Regarding knee conditions, the No-RTS group had a significantly higher knee pain intensity, as assessed using a numerical rating scale (p<0.001, effect size -0.45). In the performance tests, the No-RTS group exhibited a significantly lower limb symmetry index of RSI during the SL drop jump compared to the Yes-RTS group (p=0.002, effect size 0.81).

Conclusion

Patients unable to achieve RTS after primary ACLR using hamstring grafts are more likely to exhibit asymmetric performance during the SL drop jump test, suggesting the significance of assessing jump symmetry when evaluating post-ACLR rehabilitation success.

Level of Evidence

3c.

Factors Associated with Return to Sport After Anterior Cruciate Ligament Reconstruction: A Focus on Athletes Who Desire Preinjury Level of Sport

In most previous studies investigating return to preinjury level of sport (RTPS) after anterior cruciate ligament reconstruction (ACLR), whether patients continue aiming for RTPS not only before but also after ACLR was unclear because environmental and social factors were not considered. Herein, we aimed to evaluate factors associated with RTPS among athletes who desired to achieve RTPS even after ACLR, excluding patients who no longer desire this goal owing to environmental and social factors. Ninety-two patients who underwent primary double-bundle ACLR with a minimum 2-year follow-up and desired to achieve RTPS before surgery were retrospectively enrolled. Twelve (13%) patients who no longer desired to achieve RTPS after ACLR owing to environmental and social factors were excluded. Sixty-nine patients were included in the final cohort. At the final follow-up, the patients were split into two groups: those who achieved (R group) or did not achieve (N group) RTPS based on patient self-assessment. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Lysholm scores were also determined. The anterior tibial translation in the Lachman test and acceleration and external rotational angular velocity (ERAV) in the pivot shift test were measured at the hardware removal operation. Significant differences were observed for preinjury level of sports between the groups (p < 0.05). The rate of RTPS in competitive athletes was lower than that in recreational athletes (20/46: 43% vs. 16/22: 73%; p =.037). Lysholm score, KOOS symptom, pain, and quality of life showed higher values in the R group than in the N group (p < 0.050). Acceleration was significantly lower in the R group than in the N group (p = 0.028). Competitive level of sports is a risk factor for failure to achieve RTPS. The postoperative functional outcomes in the group that achieved RTPS showed more favorable results. These results provide important information to enable the surgeons to consider the appropriate surgical plan for competitive athletes who desire to achieve RTPS after ACLR.

Return to running criteria after anterior cruciate ligament reconstruction: an online survey of 1404 Italian physiotherapists

BACKGROUND

The aim of this study is to study the clinical decision-making practice of Italian physiotherapists in return to running (RTR) after anterior cruciate ligament (ACL) reconstruction, and the differences in decision-making in relation to physiotherapist's characteristics.

METHODS

An online survey was developed, 1404 physiotherapists were contacted by email, via chartered association, or via social media.

RESULTS

Most respondents (83%) indicated that the RTR decision should be made by a multidisciplinary team with RTR clearance around 3-4 months after surgery (47%). The most important criteria guiding the RTR decision were knee flexion range of motion (ROM) >130° (50%), complete extension ROM (95%), no pain (45%) and no effusion (68%). A Limb Symmetry Index (LSI) >70% for quadriceps (49%), hamstring (48%) and LSI >90% for posterolateral hip (45%) and triceps surae strength (42%) should be achieved for RTR. Approximately half of the participants (49%) do not consider ACL laxity tests to be used for RTR decisions. Response differences were found between sample subgroups. More experienced physiotherapists and those with post graduate training had lower thresholds to clear RTR.

CONCLUSIONS

Experienced physiotherapists who treated a higher number of patients after ACL reconstruction, who had certified specialist training and a specific interest towards ACL rehabilitation, generally reported clinical practice modalities more in line with current evidence.

Relationship between Kinesiophobia and Dynamic Postural Stability after Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study

Anterior cruciate ligament (ACL) injuries in young, active patients generally require ACL reconstruction (ACLR) to restore mechanical and postural stability. The fear of movement or reinjury (kinesiophobia) has become increasingly recognized in the post-ACLR population; however, the association between restoration of postural stability and kinesiophobia remains largely unknown. The purpose of this study was to investigate changes in mean Tampa Scale of Kinesiophobia-11 (TSK-11), dynamic motion analysis (DMA) scores, and time on the testing platform, as well as any correlation between TSK-11 and mean overall and individual translational and rotational DMA scores during the first 12 months following ACLR. Cohort study. Patients undergoing ACLR were prospectively enrolled and dynamic postural stability and kinesiophobia based on the TSK-11 were collected within 2 days prior to surgery and at 6 and 12 months following ACLR. Dynamic postural stability was quantified by calculating a DMA score, with score calculated in three translational (anterior/posterior [AP], up/down [UD], medial/lateral [ML]) and three rotational (left/right [LR], flexion/extension, and internal/external rotation) independent planes of motions. Correlations between DMA and TSK-11 scores at each time point were analyzed. A total of 25 patients meeting inclusion criteria were analyzed. Mean overall DMA and TSK-11 scores increased with each successive testing interval. At 6-month follow-up, a weakly positive association between TSK-11 and DMA scores was appreciated based on overall DMA, AP, UD, ML, and LR. At 12 months, a moderately positive correlation was appreciated between TSK-11 and the translational, but not rotational, planes of motion. Following ACLR, lower level of kinesiophobia were found to be moderately associated with improved dynamic stability, especially in the translation planes of motion.

Lateral extra-articular tenodesis in association to All-inside anterior cruciate ligament reconstruction does not modify return to play in basketball players: A comparative cohort study

INTRODUCTION

Return to play rates after anterior cruciate ligament (ACL) reconstruction range between 50-98% depending on sport professionality, without being modified by the addition of an extra-articular augmentation (EA). The objective of the study is to describe the rate of return to play in our cohort. The hypothesis is that the addition of EA increases that rate.

MATERIAL AND METHODS

A retrospective, descriptive and analytical study of a 130 basketball players cohort between 18 and 45 years old, whom underwent ACL reconstruction between the years 2018 and 2022, with a minimum follow-up of 18 months. Data was collected by reviewing medical records. IKDC score was registered after one year from surgery. All patients operated from 2020 received an extra-articular tenodesis.

RESULTS

Of all patients, 72.31% returned to training, 70.77% returned to competition and 46.15% returned to the same level of performance prior to injury. The EA group (46.15%) did not increase the rate of return to competition (P=.552) nor to the same level of performance (P=.664). The mean IKDC. score was 86.83 (SD 14.85), and was not higher in the EA group (P=.418). However, its value was higher in the players who returned to training, competition and level of performance (P<.05). EA did not delay the return to play in any group (P=.282).

CONCLUSION

To sum up, the EA does not modify the return to sport rate. Higher IKDC values predict a greater return to sport rate. in all groups. Prospective studies with larger sample size and longer follow-up time are required.

Outcomes After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon in Adolescent Athletes at Mean Follow-up of 4 Years

Background

Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes.

Purpose

To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR.

Study Design

Case series; Level of evidence, 4.

Methods

All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not.

Results

A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not.

Conclusion

At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.

Anterior cruciate ligament-Return to sport after injury scale brief version after ACL reconstruction: Persian translation, cross-cultural adaptation and validation

Purpose

The purpose of this study is to analyze the short anterior cruciate ligament return to sport after injury (ACL-RSI) (Persian) version's cultural adaption and validity.

Methods

To assess test-retest reliability, 102 participants were filled out the short ACL-RSI(Per) scale 6 months or more after ACLR surgery. Internal consistency (Cronbach's alpha), test-retest reliability (intraclass correlation coefficients), construct validity (Pearson's r) and sensitivity (floor/ceiling effect) were determined. In addition, patient completed other relevant measures such as Lysholm scores, the hospital for special surgery ACL satisfaction survey (HSS ACL-SS), the visual analogue scale (VAS) of pain and patient's satisfaction, the Tegner activity score (TAS), the single assessment numeric evaluation (SANE) and the Cincinnati Knee Rating System (CKRS).

Results

The short ACL-RSI(Per) scale showed high internal consistency (Cronbach's alpha = 0.91) and test-retest reliability (ICC = 0.923). Significant correlations between short ACL-RSI(Per) and other scales supported validity. There was a statistically significant connection between the short ACL-RSI(Per) and the following outcomes: HSS ACL-SS (r = 0.698, p < 0.001), VAS pain (r = 0.356, p < 0.001), CKRS (r = 0.644, p < 0.001), TAS (r = 0414, p < 0.001), Lysholm score (r = 0.467, p < 0.001) and SANE score (r = 0.536; p < 0.001). In addition to a satisfactory ceiling impact (15%), a sizeable floor effect (16.7%) was also seen.

Conclusion

The short ACL-RSI(Per) scale is a reliable and valid tool for assessing psychological readiness for return to sport after ACL reconstruction in Persian.

Level of Evidence

III.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Return to sports in female athletes after anterior cruciate ligament reconstruction: A systematic review and metanalysis

IMPORTANCE

Return to sport (RTS) is considered an indicator of successful recovery after anterior cruciate ligament reconstruction (ACLR). In recent years, there has been major interest in documenting RTS following anterior cruciate ligament (ACL) injury. Despite women being at increased risk for ACL injuries and a global increase in women's participation in sports, research has not adequately focused on female athletes.

OBJECTIVE

The purpose of this study is to conduct a systematic review and meta-analysis evaluating the RTS rate in female athletes after ACLR. We hypothesize that most of the female athletes can RTS.

EVIDENCE REVIEW

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electronic databases (PubMed, Embase, and Epistemonikos) were searched for articles reporting RTS rates and contextual data in female athletes. The following search terms were used: "anterior cruciate ligament reconstruction" OR "ACL reconstruction" AND "female" OR "women" AND "return to sports" OR "return to play" to retrieve all relevant articles published between 2003 and 2023. A quality assessment of the included studies was conducted.

FINDINGS

Fifteen articles were included, reporting on 1456 female athletes participating in pivoting sports. The included studies comprised 9 cohorts, 1 case-control study, 2 case series, 2 descriptive epidemiology studies, and 1 observational study. Eight out of fifteen studies focused solely on elite-level athletes. The participants had a mean age of 23.13 years. Soccer was the most prevalent sport among the participants, accounting for 49.7% of all athletes included. All 15 studies reported an RTS rate, yielding a meta-proportion of 69% [95% CI, 58-80%] for RTS. Nine articles reported the average time to RTS, which was 10.8 months [95% CI, 8.7-12.8 months].

CONCLUSIONS

This systematic review demonstrates that a majority of female athletes (69 ​%) can RTS participation at an average of 10.8 months, however, the available information is insufficient, and quantitative data and reasons for not returning to play are lacking. Future studies should establish return-to-play criteria in this population and determine reasons for not returning to play.

LEVEL OF EVIDENCE

III.

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/ .

Psychosocial experiences of competitive rugby players on the "long, long journey" to recovery following ACL ruptures and reconstruction

Anterior Cruciate Ligament (ACL) injuries are serious and potentially career-ending. Reconstruction surgery and extended rehabilitation typically follow, but some athletes never attain the same level of sport performance. The psychosocial experiences of athletes who sustain ACL injuries and their cognitive appraisal, emotional and behavioral responses to the injury, and reconstruction require further attention during the different recovery phases. The aim is to explore these psychosocial experiences, social support needs and sources thereof of competitive athletes who sustained unilateral ACL ruptures and underwent reconstruction surgery. Semi-structured interviews with six competitive rugby players (M age: 22.3 ± 2.92 years), elicited information at seven time-points. We analyzed the qualitative information through thematic analysis. Five common themes emerged: (1) cognitive appraisal, (2) emotional responses (negative and positive affective responses), (3) behavioral responses, (4) social support needs and sources thereof, and (5) adversity-induced identity expansion (athletic and person-centered identities). In-vivo quotes gave a rich description of the athletes' experiences throughout the "long, long journey" to return-to-sport. These findings may sensitize and assist sports healthcare professionals, coaches, teammates, family, and friends to explore various psychosocial experiences throughout the injury and recovery period. Phase-appropriate psychosocial support or referral to sport psychology services is recommended to enhance the recovery process, improve long-term physical and mental health, and subsequent performance.

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.

The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions

CONTEXT

Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed.

EVIDENCE ACQUISITION

Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR.

CONCLUSION

The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT)

B.

The increased lateral tibial slope may result in inferior long-term clinical outcome after DB-ACL reconstruction

PURPOSE

To determine if there is a correlation between lateral tibial slope and long-term clinical results in patients who underwent double-bundle ACL reconstruction.

METHODS

We retrospectively reviewed patients that received double-bundle ACL reconstruction at a single institution by a single surgeon from January 2011 to December 2014. All the magnetic resonance imaging were reviewed and lateral tibial slopes (LTS) were recorded by an experienced surgeon and rechecked by the other two authors of this study that specialized in orthopedic knee surgery. The relationship between PROMs measurement and lateral tibial slope were analyzed. The patients were then separated into two groups (LTS > 7.4° and < 7.4°) according to the previous study.

RESULTS

A total of 119 patients were enrolled in this study. All enrolled patients were followed for at least 8 years. The PROMS result were negatively correlated with the lateral tibial slope (p values all < 0.001). The patients with high lateral tibial slope had significantly lower PROMS values (Lysholm 94.26 ± 5.61 vs 80.15 ± 8.28, p = 0.013; IKDC 82.99 ± 4.55 vs 70.09 ± 7.15, p = 0.003; Tegner 9.32 ± 0.95 vs 6.85 ± 1.99, p < 0.001). Finally, the LTS cutoff value between patients with "Good" and "Fair" Lysholm score in our study was 7.55 degrees.

CONCLUSIONS

Patients with high lateral tibial slope may result in inferior long-term subjective outcomes. The using of double-bundle ACL reconstruction along cannot overcome the negative impact caused by steep lateral tibial slope. A lateral tibial slope of 7.55° may be used as a cut-off for a good clinical outcome.

LEVEL OF EVIDENCE

III retrospective comparative prognostic trial.

Only 10% of Patients With a Concomitant MCL Injury Return to Their Preinjury Level of Sport 1 Year After ACL Reconstruction: A Matched Comparison With Isolated ACL Reconstruction

BACKGROUND

There is a need for an increased understanding of the way a concomitant medial collateral ligament (MCL) injury may influence outcome after anterior cruciate ligament (ACL) reconstruction.

HYPOTHESIS

Patients with a concomitant MCL injury would have inferior clinical outcomes compared with a matched cohort of patients undergoing ACL reconstruction without an MCL injury.

STUDY DESIGN

Matched registry-based cohort study; case-control.

LEVEL OF EVIDENCE

Level 3.

METHODS

Data from the Swedish National Knee Ligament Registry and a local rehabilitation outcome registry were utilized. Patients who had undergone a primary ACL reconstruction with a concomitant nonsurgically treated MCL injury (ACL + MCL group) were matched with patients who had undergone an ACL reconstruction without an MCL injury (ACL group), in a 1:3 ratio. The primary outcome was return to knee-strenuous sport, defined as a Tegner activity scale ≥6, at the 1-year follow-up. In addition, return to preinjury level of sport, muscle function tests, and patient-reported outcomes (PROs) were compared between the groups.

RESULTS

The ACL + MCL group comprised 30 patients, matched with 90 patients in the ACL group. At the 1-year follow-up, 14 patients (46.7%) in the ACL + MCL group had return to sport (RTS) compared with 44 patients (48.9%) in the ACL group (P = 0.37). A significantly lower proportion of patients in the ACL + MCL group had returned to their preinjury level of sport compared with the ACL group (10.0% compared with 25.6%, adjusted P = 0.01). No differences were found between the groups across a battery of strength and hop tests or in any of the assessed PROs. The ACL + MCL group reported a mean 1-year ACL-RSI after injury of 59.4 (SD 21.6), whereas the ACL group reported 57.9 (SD 19.4), P = 0.60.

CONCLUSION

Patients with a concomitant nonsurgically treated MCL injury did not return to their preinjury level of sport to the same extent as patients without an MCL injury 1 year after ACL reconstruction. However, there was no difference between the groups in terms of return to knee strenuous activity, muscle function, or PROs.

CLINICAL RELEVANCE

Patients with a concomitant nonsurgically treated MCL injury may reach outcomes similar to those of patients without an MCL injury 1 year after an ACL reconstruction. However, few patients return to their preinjury level of sport at 1 year.

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.

Return to Play After Femoroacetabular Impingement

PURPOSE OF REVIEW

Femoroacetabular impingement (FAI) is a pathomechanical process whereby abnormal contact between proximal femur and acetabulum at end range of hip motion induces chondrolabral lesions within the hip joint. Surgery followed by a rehabilitation program or physical therapy with possible addition of an intra-articular corticosteroid injection are the two predominant treatments. The majority of authors recognize that a well-designed rehabilitation protocol is essential to achieve good outcomes with both nonoperative and surgical treatment. However, there is little evidence about what is the best rehabilitation protocol and most of the literature available is based on expert level opinion. This current review investigates the recent literature on nonoperative and postoperative rehabilitation protocol and return to play in FAI patients and describes our approach.

RECENT FINDINGS

Historically, rehabilitation protocols for treatment of FAI as well as return to play protocols were based on experts' opinion and low-level evidence studies. In order to improve standardization of protocols and to allow a better comparison in between different protocols, different authors have created standardized rehabilitation protocols with consensus building methods comparing them with other treatment options in high-level evidence trials (FASHIoN trial, etc.). Despite the excellent results reported after nonoperative and post-surgical rehabilitation, and the high RTP rate after FAI treatment, there is a significant variability in between protocols. Further high-level evidence studies are necessary in order to establish a gold standard in rehabilitation and RTP protocols.

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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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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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).

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction

OBJECTIVES

To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R).

METHODS

Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS.

RESULTS

A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures.

CONCLUSION

Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

Differences in psychological readiness for return to sport after anterior cruciate ligament injury is evident in thigh musculature motor unit characteristics

Background

Following anterior cruciate ligament (ACL) injury, many athletes that undergo surgery and 6-9 months of rehabilitation struggle to return to sport. Evidence suggests that psychological factors contribute to this failure to return-to-sport.

Objective

Determine the motor control relationship between thigh musculature motor unit characteristics and psychological readiness to return to sport between ACL-injured and healthy controls.

Study design

A longitudinal cohort study.

Methods

Athletes longitudinally completed the ACL Return to Sport after Injury (ACL-RSI) survey and isometric strength measures with a measurement of electromyography (EMG) of the vastus lateralis, vastus medialis, biceps femoris, and semitendinosus. A score cut-off of 61 on the ACL-RSI was used to divide ACL-injured groups. EMG was decomposed to provide each identified motor unit's characteristics (amplitude, average firing rate, etc).

Results

Data demonstrated increased average firing rate for hamstrings (p<0.001), decreased average firing rate for vastus lateralis (p<0.001) and decreased motor unit size for both the quadriceps and hamstrings at return-to-sport post-ACL reconstruction compared with sex-matched and age-matched healthy controls (p<0.001). Furthermore, there were marked differences in disparate ACL-RSI scores between ACL-injured athletes.

Conclusions

At return to sport, ACL-injured athletes have major alterations of thigh musculature motor control, with smaller motor units used by those with low ACL-RSI scores. This study uniquely demonstrates objective thigh muscle motor unit characteristics that coincide with subjective reports of psychological readiness. This information will be important to address psychomotor complexes of injury for future rehabilitation protocols.

Aetiological Factors of Running-Related Injuries: A 12 Month Prospective "Running Injury Surveillance Centre" (RISC) Study

BACKGROUND

Running-related injuries (RRIs) are a prevalent issue for runners, with several factors proposed to be causative. The majority of studies to date are limited by retrospective study design, small sample sizes and seem to focus on individual risk factors in isolation. This study aims to investigate the multifactorial contribution of risk factors to prospective RRIs.

METHODS

Recreational runners (n = 258) participated in the study, where injury history and training practices, impact acceleration, and running kinematics were assessed at a baseline testing session. Prospective injuries were tracked for one year. Univariate and multivariate Cox regression was performed in the analysis.

RESULTS

A total of 51% of runners sustained a prospective injury, with the calf most commonly affected. Univariate analysis found previous history of injury < 1 year ago, training for a marathon, frequent changing of shoes (every 0-3 months), and running technique (non-rearfoot strike pattern, less knee valgus, greater knee rotation) to be significantly associated with injury. The multivariate analysis revealed previous injury, training for a marathon, less knee valgus, and greater thorax drop to the contralateral side to be risk factors for injury.

CONCLUSION

This study found several factors to be potentially causative of injury. With the omission of previous injury history, the risk factors (footwear, marathon training and running kinematics) identified in this study may be easily modifiable, and therefore could inform injury prevention strategies. This is the first study to find foot strike pattern and trunk kinematics to relate to prospective injury.

Early MRI-based quantitative outcomes are associated with a positive functional performance trajectory from 6 to 24 months post-ACL surgery

PURPOSE

Quantitative magnetic resonance imaging (qMRI) has been used to determine the failure properties of ACL grafts and native ACL repairs and/or restorations. How these properties relate to future clinical, functional, and patient-reported outcomes remain unknown. The study objective was to investigate the relationship between non-contemporaneous qMRI measures and traditional outcome measures following Bridge-Enhanced ACL Restoration (BEAR). It was hypothesized that qMRI parameters at 6 months would be associated with clinical, functional, and/or patient-reported outcomes at 6 months, 24 months, and changes from 6 to 24 months post-surgery.

METHODS

Data of BEAR patients (n = 65) from a randomized control trial of BEAR versus ACL reconstruction (BEAR II Trial; NCT02664545) were utilized retrospectively for the present analysis. Images were acquired using the Constructive Interference in Steady State (CISS) sequence at 6 months post-surgery. Single-leg hop test ratios, arthrometric knee laxity values, and International Knee Documentation Committee (IKDC) subjective scores were determined at 6 and 24 months post-surgery. The associations between traditional outcomes and MRI measures of normalized signal intensity, mean cross-sectional area (CSA), volume, and estimated failure load of the healing ACL were evaluated based on bivariate correlations and multivariable regression analyses, which considered the potential effects of age, sex, and body mass index.

RESULTS

CSA (r = 0.44, p = 0.01), volume (r = 0.44, p = 0.01), and estimated failure load (r = 0.48, p = 0.01) at 6 months were predictive of the change in single-leg hop ratio from 6 to 24 months in bivariate analysis. CSA (βstandardized = 0.42, p = 0.01), volume (βstandardized = 0.42, p = 0.01), and estimated failure load (βstandardized = 0.48, p = 0.01) remained significant predictors when considering the demographic variables. No significant associations were observed between MRI variables and either knee laxity or IKDC when adjusting for demographic variables. Signal intensity was also not significant at any timepoint.

CONCLUSION

The qMRI-based measures of CSA, volume, and estimated failure load were predictive of a positive functional outcome trajectory from 6 to 24 months post-surgery. These variables measured using qMRI at 6 months post-surgery could serve as prospective markers of the functional outcome trajectory from 6 to 24 months post-surgery, aiding in rehabilitation programming and return-to-sport decisions to improve surgical outcomes and reduce the risk of reinjury.

LEVEL OF EVIDENCE

Level II.

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).

London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport

Hamstring injuries (HSIs) are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades. HSI often recur and many areas are lacking evidence and guidance for optimal rehabilitation. This study aimed to develop an international expert consensus for the management of HSI. A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering round questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15), comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion around each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. Consensus threshold was set a priori at 70%. Expert response rates were 35/46 (76%) (first round), 15/35 (attendees/invitees to meeting day) and 99/112 (88.2%) for final survey round. Statements on rehabilitation reaching consensus centred around: exercise selection and dosage (78.8%-96.3% agreement), impact of the kinetic chain (95%), criteria to progress exercise (73%-92.7%), running and sprinting (83%-100%) in rehabilitation and criteria for return to sport (RTS) (78.3%-98.3%). Benchmarks for flexibility (40%) and strength (66.1%) and adjuncts to rehabilitation (68.9%) did not reach agreement. This consensus panel recommends individualised rehabilitation based on the athlete, sporting demands, involved muscle(s) and injury type and severity (89.8%). Early-stage rehab should avoid high strain loads and rates. Loading is important but with less consensus on optimum progression and dosage. This panel recommends rehabilitation progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting (85.5%). Experts focus on the demands and capacity required for match play when deciding the rehabilitation end goal and timing of RTS (89.8%). The expert panellists in this study followed evidence on aspects of rehabilitation after HSI, suggesting rehabilitation prescription should be individualised, but clarified areas where evidence was lacking. Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit optimising: prescription of running and sprinting, the application of adjuncts in rehabilitation and treatment of kinetic chain HSI factors.

There Is Substantial Variation in Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction: A Survey of 46 American Orthopaedic Surgeons

PURPOSE

To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM).

METHODS

An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process.

RESULTS

Responses from 46 orthopaedic surgeons were analyzed. Patient-reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty-eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return-to-sport phases, respectively.

CONCLUSIONS

This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision-making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice.

CLINICAL RELEVANCE

Postoperative rehabilitative protocols after ACLR vary by surgeon.

Return to Sport After Anterior Cruciate Ligament Reconstruction Requires Evaluation of >2 Functional Tests, Psychological Readiness, Quadriceps/Hamstring Strength, and Time After Surgery of 8 Months

PURPOSE

The purpose of this study was to examine the factors commonly used to determine readiness for return to sport (RTS) in the ACL reconstruction (ACL-R) patient population and assess which were most influential to successfully returning to sport and avoiding re-tear.

METHODS

The PUBMED, EMBASE and Cochrane Library databases were queried for studies related to RTS in ACL-R. Inclusion and exclusion criteria were applied to identify studies with greater than 1-year outcomes detailing the rate of return and re-tear given a described RTS protocol. Data of interest were extracted, and studies were stratified based on level of evidence and selected study features. Meta-analysis or subjective synthesis of appropriate studies was used to assess more than 25 potentially significant variables effecting RTS and re-tear.

RESULTS

After initial search of 1503 studies, 47 articles were selected for inclusion in the final data analysis, including a total of 1432 patients (31.4% female, 68.6% male). A meta-analysis of re-tear rate for included Level of Evidence 1 studies was calculated to be 2.8%. Subgroups including protocols containing a strict time until RTS, strength testing, and ≥2 dynamic tests demonstrated decreased RTS and re-tear heterogeneity from the larger group. Time to RTS, strength testing, dynamic functional testing, and knee stability were also found to be among the most prevalent reported criteria in RTS protocol studies.

CONCLUSIONS

This study suggests a multifactorial clinical algorithm for successful evaluation of RTS. The "critical criteria" recommended by the authors to be part of the postoperative RTS criteria include time since surgery of 8 months, use of >2 functional tests, psychological readiness testing, and quadriceps/hamstring strength testing in addition to the modifying patient factors of age and female gender.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients

Background

The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown.

Purpose/Hypothesis

The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity.

Study Design

Cohort study; Level of evidence, 3.

Methods

From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test.

Results

Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months.

Conclusion

At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Patients older than 55 years regain sporting and recreational activities after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

(1) To compare sporting and recreational activity levels before and at a minimum 6 year follow-up, and (2) to assess the clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction in patients older than 55 years.

METHODS

A retrospective evaluation of prospectively collected data of 150 patients with a mean age of 64 ± 4.5 (57-74) years was evaluated 8.6 ± 1.4 (6-11) years after primary ACL reconstruction using hamstring autograft. All patients were assessed using the International Knee Documentation Committee scoring system (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity level, and visual analog scale (VAS) for pain. The level of recreational activities was assessed using a sport-specific questionnaire. All patients were categorized according to Isolated and Combined ACL injury groups.

RESULTS

The data of 125 patients were analyzed at the last follow-up. While 25 patients were lost to follow-up, 117 of 125 patients were active before their injury in at least one sports discipline compared to 121 of 125 patients after ACL reconstruction. One hundred and two (82%) patients had returned to their recreational activities at the final follow-up. The mean IKDC subjective score increased from 49.5 ± 23.2 (11.5-100) to 76.2 ± 14.8 (33.3-100) (p < 0.0001). The mean KOOS sport increased significantly from 36 ± 36.2 (0-100) to 74.1 ± 25.5 (0-100) (p < 0.0001). The mean VAS score improved from 6.0 ± 2.6 (0-10) to 1.0 ± 1.4 (0-6) (p < 0.0001). There was no significant difference in the median Tegner activity level (preoperative 5 (2-8) vs. follow-up 5 (2-8) (n.s). There was no significant difference in the number of sports disciplines and duration when comparing pre-injury and mid-term follow-up activity after ACL reconstruction. High-impact activities experienced a significant decline, while a significant increase in participation in low-impact activities was recorded.

CONCLUSION

The majority of patients with symptomatic instability regained their pre-injury recreational activity level with excellent clinical and functional outcomes after arthroscopic ACL reconstruction. Nevertheless, a change from high-to low-impact activities has been observed.

LEVEL OF EVIDENCE

Level IV.

Unilateral tests of lower-limb function as prognostic indicators of future knee-related outcomes following anterior cruciate ligament injury: a systematic review and meta-analysis of 13 150 adolescents and adults

OBJECTIVE

To investigate the prognostic capacity of individual hop tests, hop test batteries and other unilateral functional performance tests following anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Six databases searched up to June 2021.

ELIGIBILITY CRITERIA

Studies reporting associations between unilateral lower-limb function (eg, hop tests) following ACL injury and future (≥3 months) knee-related outcomes.

RESULTS

Of 42 included studies (13 150 participants), all assessed the single-forward hop test and 32 assessed a repeated-forward hop test (crossover hop, triple hop, 6m-timed hop), mostly within a year after ACL injury/reconstruction. Results of meta-analyses indicated that higher single-forward and repeated-forward hop limb symmetry were associated with higher odds of return-to-sport 1-3 years post-ACL reconstruction (OR 2.15; 95% CI 1.30 to 3.54; OR 2.11; 95% CI 1.23 to 3.60, respectively). Higher single-forward and repeated-forward hop limb symmetry was associated with better self-reported symptoms and function 1-37 years after ACL injury (OR 2.51; 95% CI 1.62 to 3.88; OR 4.28; 95% CI 1.65 to 11.08, respectively). Higher limb symmetry on a repeated-forward hop does not appear to be associated with higher odds of successful rehabilitation without ACL reconstruction (OR 1.51; 95% CI 0.94 to 2.44). Achieving ≥90% limb symmetry on the single-forward hop was associated with reduced odds of knee osteoarthritis 5-37 years after ACL injury (OR 0.46; 95% CI 0.23 to 0.94).

CONCLUSION

Very low certainty evidence suggests single-forward and repeated-forward hop tests are prognostic indicators for important knee-related outcomes in individuals after ACL injury and may help stratify individuals at risk of poor outcomes to target rehabilitation interventions.

PROSPERO REGISTRATION NUMBER

CRD42018092197.

Early outcomes of primary repair versus reconstruction for acute anterior cruciate ligament injury: A systematic review and meta-analysis

BACKGROUND

Contemporary techniques for repair of acute anterior cruciate ligament (ACL) rupture have been receiving renewed interest recently because of reports of good outcomes.

METHODS

A literature search of PUBMED, MEDLINE, EMBASE, and the Cochrane Library was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only RCTs published in English and comparing clinical outcomes of ACL repair versus reconstruction were included. Outcomes were evaluated using the International Knee Documentation Committee subjective score, Lysholm score, Tegner activity scale, visual analog scale pain score, anterior laxity, Lachman test, hop tests, knee injury and osteoarthritis outcome score, extension deficit, revision rate, and re-rupture rate. Statistical analysis was performed with Review Manager 5.4 and Stata 14.0. Two-tailed P < .05 was considered statistically significant.

RESULTS

Four RCTs (with a total of 293 patients) that met the eligibility criteria were included in this review. Over short-term follow-up, none of the studies found significant differences between the repair groups and reconstruction groups with respect to International Knee Documentation Committee, Lysholm, Tegner, visual analog scale, anterior laxity, Lachman test, re-rupture rate, extension deficit, and performance of 3 hop tests (P > .05). In both groups, the hop tests scores were >90%.

CONCLUSION

ACL repair and ACL reconstruction appear to provide comparable short-term outcomes. The low revision rate after primary repair is encouraging. For patients with ACL injury, current repair techniques such as dynamic intraligamentary stabilization and bridge-enhanced ACL repair may be an effective alternative to reconstruction.

Changes in subjective knee function and psychological status from preoperation to 6 months post anterior cruciate ligament reconstruction

Purpose

To determine characteristic changes in subjective knee function, kinesiophobia, and psychological readiness to return to sports between scores taken before anterior cruciate ligament reconstruction (ACLR) and those taken 6 months post-ACLR.

Methods

Thirty-two participants (median age, 20.0 years) were included. Subjective knee function was assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). The Tampa Scale for Kinesiophobia (TSK-11) and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale were used to evaluate kinesiophobia and psychological readiness to return to sport, respectively. Questionnaires were administered 1 day before surgery and at 6 months post-ACLR. A positive change was defined as an increase in IKDC-SKF and ACL-RSI scores and a decrease in TSK-11 score. The change in each score from pre-ACLR to 6 months post-ACLR was analyzed using a paired t-test. The percentage change in scores was calculated, and the correlations of the percentage change in the TSK-11 and ACL-RSI scores and that in the IKDC-SKF score were analyzed.

Results

All scores differed significantly positively from pre-ACLR to 6 months post-ACLR. The proportion of participants whose scores did not change positively from pre-ACLR to 6 months post-ACLR was higher for the TSK-11 (38.0%) and ACL-RSI (38.0%) than for the IKDC-SKF (6.3%). No correlation was observed between the percentage change in the IKDC-SKF score and that in the TSK-11 or ACL-RSI scores from pre-ACLR to 6 months post-ACLR.

Conclusions

Changes in subjective knee function and psychological status from pre-ACLR and 6 months post-ACLR may not be interdependent.

Range of Motion, Strength, and Function After ACL Reconstruction Using a Contralateral Patellar Tendon Graft

BACKGROUND

Regaining preinjury levels of activity and progressing rehabilitation factors after anterior cruciate ligament (ACL) reconstruction have shown mixed results.

PURPOSE

To evaluate the timing and rate of return for knee range of motion (ROM), stability, strength, and subjective scores after ACL reconstruction with contralateral patellar tendon graft (PTG).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Included were 2148 patients (1238 male patients, 910 female patients) who underwent primary ACL reconstruction with a contralateral PTG between 1995 and 2017 and had complete objective data through 3 months of follow-up. All patients participated in a rehabilitation program specific to goals for each knee. Patients were evaluated objectively with goniometric measurement of ROM, isokinetic quadriceps strength testing, and laxity with a KT-2000 arthrometer. Subjective data were collected at 2 and 5 years.

RESULTS

Normal extension on the reconstructed knee was attained for 95% of patients at 1 week postoperatively; normal flexion on the reconstructed knee was reached by 77% of patients by 3 months. At 3 months postoperatively, mean limb symmetry index strength was 104%, and the strength on the ACL-reconstructed and graft-donor knees was 87% and 86% of their respective preoperative strength. Mean manual maximum side-to-side difference in laxity was 2.0 mm at 1 month. Most patients (90%) returned to level 8 sports or higher and did so at an average of 5.7 months. Mean International Knee Documentation Committee scores for the ACL-reconstructed and graft-donor knees were 89 and 91 at 2 years (n = 1015 patients) and 84 and 90 at 5 years (n = 1275 patients), respectively. Mean Cincinnati Knee Rating Scale scores for the ACL-reconstructed and graft-donor knees were 92 and 96 at 2 years (n = 1184) and 88 and 94 at 5 years (n = 1236), respectively.

CONCLUSION

For patients who underwent ACL reconstruction with a contralateral PTG, postoperative ROM and strength were restored quickly by splitting the rehabilitation into different goals between the two knees. Using a contralateral PTG, this structured rehabilitation plan can lead to a relatively quick return to sport and good subjective long-term outcomes.

Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 ​years

OBJECTIVES

To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years.

METHODS

Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests.

RESULTS

45 QT-A patients were matched to 45 HT-A patients (n ​= ​90). The mean FU was 78.9 ​± ​13.6 months. 18 patients (20.0%/QT-A: N ​= ​8, 17.8%; HT-A: n ​= ​10, 22.2%; p ​= ​.60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n ​= ​9, 20.0%; HT-A: n ​= ​8, 17.8%; p ​= ​.79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p ​= ​.32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 ​± ​11.6 years, HT-A: 23.3 ​± ​9.5 years, p ​= ​.63) or graft thickness (mean graft square area: QT-A: 43.6 ​± ​4.7 mm², HT-A: 48.1 ​± ​7.9 mm², p ​= ​.27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 ​± ​1.2 ​mm, HT-A: 2.1 ​± ​1.5 ​mm; p ​= ​.60), subjective IKDC- (QT-A: 93.8 ​± ​6.8, HT-A: 91.2 ​± ​7.8, p ​= ​.17), Lysholm- (QT-A 91.9 ​± ​7.2, HT-A: 91.5 ​± ​9.7, p ​= ​.75) or any of the five subscales of the KOOS score (all p ​> ​.05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p ​= ​.62), VAS for pain (QT-A: 0.5 ​± ​0.9, HT-A: 0.6 ​± ​1.0, p ​= ​.64), Shelbourne-Trumper score (QT-A: 96.5 ​± ​5.6, HT-A: 95.2 ​± ​8.2, p ​= ​.50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 ​± ​3.2, HT-A: 10.7 ​± ​4.9, p ​= ​.24), SSD-DTC (QT-A: 0.5 ​± ​0.5, HT.- A: 0.5 ​± ​0.6, p ​= ​.97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 ​± ​3.8%, HT-A: 93.7 ​± ​7.0%) did not differ between groups. Donor-site morbidity (HT-A n ​= ​14, 46.7%; QT-A n ​= ​3, 11.5%; p ​= ​.008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p ​= ​.29).

CONCLUSION

Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft.

LEVEL OF EVIDENCE

II.

Relationship of the SIRSI Score to Return to Sports After Surgical Stabilization of Glenohumeral Instability

BACKGROUND

Literature is scarce regarding the influence of psychological readiness on return to sports after shoulder instability surgery.

PURPOSE

To evaluate the predictive ability of the Shoulder Instability-Return to Sport after Injury (SIRSI) score in measuring the effect of psychological readiness on return to sports and to compare it between athletes who returned to sports and athletes who did not return to sports.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective analysis was performed of patients who underwent an arthroscopic Bankart repair or a Latarjet procedure between January 2019 and September 2020. Psychological readiness to return to play was evaluated using the SIRSI instrument. Preoperative and postoperative functional outcomes were measured by the Rowe, Athletic Shoulder Outcome Scoring System, and Western Ontario Shoulder Instability Index scores. The predictive validity of the SIRSI was assessed by the use of receiver operating characteristic (ROC) curve statistics. The Youden index was calculated and used to determine a SIRSI score cutoff point that best discriminated psychological readiness to return to sports. A logistic regression analysis was performed to evaluate the effect of psychological readiness on return to sports and return to preinjury sports level.

RESULTS

A total of 104 patients were included in this study. Overall, 79% returned to sports. The SIRSI had excellent predictive ability for return-to-sport outcomes (return to sports: area under ROC curve, 0.87 [95% CI, 0.80-0.93]; return to preinjury sports level: area under ROC curve, 0.96; [95% CI, 0.8-0.9]). A cutoff level of ≥55 was used to determine whether an athlete was psychologically ready to return to sports and to return to preinjury sports level (Youden index, 0.7 and 0.9, respectively). Of those who returned to sports, 76.8% were psychologically ready to return to play, with a median SIRSI score of 65 (interquartile range, 57-80). In comparison, in the group that did not return to sports, only 4.5% achieved psychological readiness with a median SIRSI score of 38.5 (interquartile range, 35-41) (P < .001). Regression analysis for the effect of SIRSI score on return to sports was performed. For every 10-point increase in the SIRSI score, the odds of returning to sports increased by 2.9 times. Moreover, those who did not achieve their preinjury sports level showed poorer psychological readiness to return to play and SIRSI score results.

CONCLUSION

The SIRSI was a useful tool for predicting whether patients were psychologically ready to return to sports after glenohumeral stabilization surgery. Patients who returned to sports and those who returned to their preinjury sports level were significantly more psychologically ready than those who did not return. Therefore, we believe that the SIRSI score should be considered along with other criteria that are used to decide whether the patient is ready to return to sports.

Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction in the Adolescent Athlete

CONTEXT

Psychological readiness to return to sport has been shown to be associated with future play after anterior cruciate ligament (ACL) reconstruction surgery but has not been extensively studied in adolescent athletes.

OBJECTIVE

To investigate the psychometric properties of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale in adolescent athletes at multiple time points after ACL reconstruction surgery and determine whether psychological readiness scores at 6 months predict return to competition sport at 12 months.

DESIGN

Case series.

SETTING

Private orthopaedic clinic.

PATIENTS OR OTHER PARTICIPANTS

A total of 115 adolescent athletes (65 girls, 50 boys) 17 years and younger who had undergone primary unilateral ACL reconstruction.

MAIN OUTCOME MEASURE(S)

The ACL-RSI scale was administered at 6 and 12 months after surgery, and return-to-sport status was also documented. Factor analysis was undertaken and predictive validity assessed using between-groups comparisons and receiver operating characteristic (ROC) curve statistics.

RESULTS

The ACL-RSI scores increased between 6 and 12 months (55 to 71; P < .001, effect size = 0.98). No floor or ceiling effects were present, and the scale had high internal consistency (Cronbach α at 6 months = 0.91 and at 12 months = 0.94). Principal component analysis showed that 2 factors were present: the first represented performance confidence and risk appraisal and the second, emotions. For the full-scale ACL-RSI, scores at 6 months had acceptable predictive ability for a return to play at 12 months (area under the ROC curve = 0.7, P = .03). When the 2 identified factors were analyzed separately, the emotions factor also had acceptable predictive ability (area under the ROC curve = 0.73, P = .009), but the confidence in performance and risk appraisal factors had poor predictive ability (area under the ROC curve = 0.59, P = .09).

CONCLUSIONS

Greater psychological readiness was associated with return to sport in adolescent athletes after ACL reconstruction, with the athletes' emotional response appearing to be more influential than their confidence in their performance or their appraisal of risk.

Cross-sectional study on relationships between physical function and psychological readiness to return to sport after anterior cruciate ligament reconstruction

BACKGROUND

Information about specific factors of physical function that contribute to psychological readiness is needed to plan rehabilitation for a return to sports. The purpose of this study was to identify specific physical functions related to the psychological readiness of patients aiming to return to sports 6 months after reconstruction. We hypothesized that the knee strength is a factor related to the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) cutoff score for a return to sports.

METHODS

This was a cross-sectional study. Fifty-four patients who had undergone primary reconstruction using hamstring tendon participated in this study. Psychological readiness was measured using the ACL-RSI in patients at 6 months after reconstruction. To identify specific physical functions related to the ACL-RSI score, participants were divided into groups with ACL-RSI scores of ≥ 60 or < 60. Non-paired t-tests or the Mann-Whitney test were performed to analyze group differences in objective variables in physical function: (1) knee strength in both legs; (2) leg anterior reach distance on both sides; and (3) single-leg hop (SLH) distances in three directions for both legs.

RESULTS

Significant differences between groups were identified in knee flexion strength (60°/s) for the uninvolved limb, hamstring-to-quadriceps ratio (60°/s) for the uninvolved limb, knee flexion strength (180°/s) for the involved limb, limb symmetry index (LSI) of leg anterior reach distance, the ratio of the distance to the height of the patient and LSI of SLH distances in lateral and medial directions.

CONCLUSION

This study revealed that at 6 months after reconstruction, increased knee flexion strength (ratio of peak torque measured to body mass of the patient), hamstring-to-quadriceps ratio, leg anterior reach distance LSI, and lateral and medial SLH appear important to exceed the ACL-RSI cutoff for a return to sports. The present results may be useful for planning post-operative rehabilitation for long-term return to sports after reconstruction.

Selective bundle reconstruction for symptomatic partial anterior cruciate ligament tears demonstrates good functional scores, high return to sport rates and a low re-tear rate

BACKGROUND

The treatment of symptomatic partial anterior cruciate ligament (ACL) tears remains controversial. This study investigated the clinical and functional outcome of patients undergoing selective posterolateral (PLB) or anteromedial (AMB) bundle reconstruction.

METHODS

55 consecutive patients underwent partial bundle reconstruction, of which 45 (AMB = 17, PLB = 28) were included in the current analysis (62% male, mean age of 29.1 years). Patients were assessed at 12 and 24 months with patient-reported outcome measures (PROMs), graft laxity (KT-1000), knee extensor and flexor torque and a 4-hop battery. Limb Symmetry Indices (LSIs) were calculated. Return to sport (RTS) rates, re-operations and re-injuries were evaluated.

RESULTS

High scoring PROMs were evident, with 62% and 84% of patients participating in pivoting sports at 12 and 24 months, respectively. Overall, 98% of patients demonstrated 'normal' knee laxity at 24 months. Mean LSIs for all hop tests were ≥ 90% at 12 and 24 months, with 76-87% of patients demonstrating LSIs ≥ 90% on the four hop tests employed at 12 months, which was 89-93% of patients at 24 months. A mean knee extensor torque LSI of 89% and 97% was observed at 12 and 24 months. Two ipsilateral re-tears (2/55, 3.6%, AMB = 1, PLB = 1) were observed over the 24-month period, with no contralateral ACL tears.

CONCLUSIONS

High levels of physical function and RTS were observed in patients following partial bundle reconstruction, higher than that reported in the literature in patients undergoing ACLR, without evidence of instability and a low re-injury rate.

Return to Sports After Anterior Cruciate Ligament Reconstruction: Validity and Reliability of the SPORTS Score at 6 and 12 Months

Background:

The Subjective Patient Outcome for Return to Sports (SPORTS) score is a single-item scale that measures athletes' ability to return to their preinjury sport based on effort and performance.

Purpose/Hypothesis:

The purpose of this study was to examine the psychometric properties of the SPORTS score and a modified score within the first year after anterior cruciate ligament reconstruction (ACLR). The modified version replaced “same sport” with “any sport” in the answer choices. It was hypothesized that both versions of the SPORTS score would have acceptable floor and ceiling effects and internal responsiveness, moderate convergent validity, and excellent test-retest reliability.

Study Design:

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

Methods:

Patients were recruited preoperatively from 2 academic medical centers. The authors collected responses to the 1-item SPORTS scores at 6 and 12 months after ACLR and the Tegner activity scale, Lysholm knee score, Knee injury and Osteoarthritis Outcome Score (KOOS)–sport/recreation subscale, and Marx activity rating scale preoperatively and 6 and 12 months after ACLR. Ceiling and floor effects and responsiveness were assessed using descriptive statistics and cross-tabulations, respectively, at both follow-up time points. Spearman correlations and intraclass correlation coefficients were used to examine convergent validity and test-retest reliability, respectively.

Results:

Follow-up rates at 6 and 12 months were 100% and 99%, respectively. Test-retest follow-up was 77%. Floor effects for the SPORTS scores were not observed, while ceiling effects at 12 months ranged from 38% to 40%. Cross-tabulation of the SPORTS scores showed that 64% to 66% of patients reported a change in their score from 6 to 12 months, with significant differences noted between the proportions that improved versus worsened for return to any sport. Convergent validity was observed at 6 and 12 months via moderate correlations with the Tegner, Lysholm, KOOS–sport/recreation, and Marx scores (r = 0.31 to 0.47). Fair to good test-retest reliability (intraclass correlation coefficient, 0.58 and 0.60) was found at 12 months after ACLR.

Conclusion:

The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.

Evidence for isokinetic and functional testing in return to sport decisions following ACL surgery

The rupture and reconstruction of the anterior cruciate ligament (ACL) of the knee are associated with an increased risk of functional instability, a reduction in sports performance, and a higher risk of future additional injuries. Competitive athletes who participate in sports that require pivoting, cutting, and jumping are at particularly high risk for ACL rupture. The return to sport progression continuum after surgery includes sports-specific rehabilitation, evaluation of strength and function, gradual participation in exercise training with progressively challenging activities in the field of play, participation in sports at a lower level, and finally a return to preinjury-level sports competition. This narrative review evaluates the evidence that supports the use of quadriceps and hamstrings isokinetic strength testing and sports-specific functional skills assessments to evaluate progress with rehabilitation after ACL surgery. Strength evaluations, hop tests, agility tests, and the limb symmetry index are described, as well as the associations of quadriceps and hamstrings muscle strength and functional test results with successful return to sports and the risk of ACL graft rupture and contralateral knee injuries. Suggestions for future research directions are presented including the importance of presurgery testing, standardization of test batteries, and comparison of test results with normative data.

Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review

BACKGROUND

The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities.

METHODS

A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools.

RESULTS

Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation.

CONCLUSIONS

Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria.

LEVEL OF EVIDENCE

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

Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstruction

PURPOSE

The psychological response to an Anterior Cruciate Ligament (ACL) injury is significant and can negatively impact return to sports outcomes. This study aimed to quantify the association between factors associated with return to sport using network analysis.

METHODS

441 participants who underwent primary ACL reconstruction. The 12-item ACL Return to Sport after Injury (ACL-RSI) scale was administered to all participants 12 months after surgery. Three network analyses were used to quantify the adjusted correlations between the 12 items of the ACL-RSI scale, and to determine the centrality indices of each item (i.e., the degree of connection with other items in the network). Further subgroup network analyses were conducted for those who had (n = 115) and had not returned (n = 326) to their pre-injury level of sport.

RESULTS

The greatest adjusted correlation was between Q7 and Q9 (fear of re-injury and afraid of accidentally injuring knee) of the ACL-RSI (group 0.48 (95%CI [0.40 to 0.57])) across all three networks. The most important item in the network was Q12 (relaxed about sport) across all three networks. Individuals who did return to sport had greater Strength centrality for Q8 (confidence in knee, P = 0.014) compared to those who did not return to sport.

CONCLUSION

Fear of re-injury and being relaxed about playing sport were the two most important nodes in the network models that describe the return to sport readiness. The importance of knee confidence at influencing psychological readiness was greater in athletes who did return to sport compared to those who did not. Our findings provide candidate therapeutic targets that could inform future interventions designed to optimize return to sport rates in athletes post ACL reconstruction.

Knee strength symmetry at 4 months is associated with criteria and rates of return to sport after anterior cruciate ligament reconstruction

BACKGROUND

Strength limb symmetry index (LSI) is a useful criterion to help in return-to-sport performance (RTP) after anterior cruciate ligament reconstruction (ACLR).

OBJECTIVES

We aimed to assess whether knee extensor and flexor LSI values at 4 months after ACLR are associated with those recommended at 8 months after ACLR for RTP (80%, 85% and 90%) and with successful RTP after 2 years.

METHODS

This was prospective cohort study of 113 participants who underwent primary ACLR. Personal factors such as demographic and sport information, injury and surgery characteristics were collected at 6 weeks after surgery. Isokinetic strength LSI (60°/s) was calculated at 4 months (LSI[4m]) and 8 months (LSI[8m]) for knee extensors (Q-LSI) and flexors (H-LSI). Participants were followed at 2 years after ACLR to determine their self-reported RTP. Multiple linear regression analysis was used to determine associations between personal factors and LSI at 4 and 8 months. Associations between passing the optimal cut-off thresholds and RTP were tested with chi-square tests and odds ratios (ORs) with effect sizes (ES).

RESULTS

Among the 113 participants (mean age 25.2 [SD 9.7] years; 42% females), extended tourniquet time and lower level of pre-injury sport were associated with lower Q-LSI[4m] and H-LSI[4m]. Bone-patellar tendon-bone graft was associated with lower Q-LSI[4m] and Q-LSI[8m], and older age was associated with lower Q-LSI[4m]. For knee extensors, Q-LSI[4m] >59% was associated with Q-LSI[8m] >80% (OR= 31.50, p <0.001, large ES) and increased odds of successful RTP (60% vs 31%, OR= 3.45, p= 0.003, medium ES). For knee flexors, H-LSI[4m] >72% was associated with H-LSI[8m] >90% (OR= 6.03, p <0.001, large ES) and increased odds of successful RTP (53% vs 23%, OR= 3.76, p= 0.013, small-to-medium ES).

CONCLUSIONS

After primary ACLR, 4-month post-operative strength symmetry was negatively associated with age, pre-injury sport and tourniquet time and bone-patellar tendon-bone graft. Four-month post-operative LSI was associated with 8-month post-operative LSI, and Q-LSI[4m] >59% or H-LSI[4m] >72% was associated with increased RTP rates after 2 years. CLINICALTRIALS.GOV: : NCT04071912.